Provider Demographics
NPI:1588172571
Name:DENTAL SUMMIT PLLC
Entity type:Organization
Organization Name:DENTAL SUMMIT PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NODESH
Authorized Official - Middle Name:BANGALORE
Authorized Official - Last Name:SHYAMSUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:BDS
Authorized Official - Phone:904-246-6714
Mailing Address - Street 1:324 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5602
Mailing Address - Country:US
Mailing Address - Phone:904-246-6714
Mailing Address - Fax:
Practice Address - Street 1:324 3RD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5602
Practice Address - Country:US
Practice Address - Phone:904-246-6714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN209071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty