Provider Demographics
NPI:1992806335
Name:CAROLINA DENTURES & DENTISTRY
Entity type:Organization
Organization Name:CAROLINA DENTURES & DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:FAVALA
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-489-0707
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:10701 US HWY 41 NORTH DUNNELLON
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432
Mailing Address - Country:US
Mailing Address - Phone:352-489-0707
Mailing Address - Fax:352-489-1525
Practice Address - Street 1:10701 US HWY 41 NORTH DUNNELLON
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432
Practice Address - Country:US
Practice Address - Phone:352-489-0707
Practice Address - Fax:352-489-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011269261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental