Provider Demographics
NPI:1447268354
Name:LAFAYETTE COUNTY HEALTH DEPARTMENT-DENTAL CLINIC
Entity type:Organization
Organization Name:LAFAYETTE COUNTY HEALTH DEPARTMENT-DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-362-2708
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-1806
Mailing Address - Country:US
Mailing Address - Phone:386-294-1321
Mailing Address - Fax:386-294-3457
Practice Address - Street 1:140 SW VIRGINIA CIR
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-4064
Practice Address - Country:US
Practice Address - Phone:386-294-2012
Practice Address - Fax:386-294-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 14318251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare