Provider Demographics
NPI:1588296883
Name:TAVARES DENTAL PLLC
Entity type:Organization
Organization Name:TAVARES DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-971-2283
Mailing Address - Street 1:838 HIGHWAY 466
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3918
Mailing Address - Country:US
Mailing Address - Phone:801-971-2283
Mailing Address - Fax:
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3809
Practice Address - Country:US
Practice Address - Phone:352-343-2821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental