Provider Demographics
NPI:1851118475
Name:LEGACY DENTAL STUDIO, LLC
Entity type:Organization
Organization Name:LEGACY DENTAL STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:REESE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-818-9006
Mailing Address - Street 1:50 ORIGINS MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INLET BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32461
Mailing Address - Country:US
Mailing Address - Phone:850-818-9006
Mailing Address - Fax:
Practice Address - Street 1:50 ORIGINS MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:INLET BEACH
Practice Address - State:FL
Practice Address - Zip Code:32461
Practice Address - Country:US
Practice Address - Phone:850-818-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty