Provider Demographics
NPI:1447483920
Name:PARK DENTAL OF OCALA, PA
Entity type:Organization
Organization Name:PARK DENTAL OF OCALA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-861-2510
Mailing Address - Street 1:3101 SW 34TH AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-8476
Mailing Address - Country:US
Mailing Address - Phone:352-861-2510
Mailing Address - Fax:352-861-2498
Practice Address - Street 1:3101 SW 34TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-8476
Practice Address - Country:US
Practice Address - Phone:352-861-2510
Practice Address - Fax:352-861-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1902005903OtherINDIVIDUAL NPI FOR DR LARSON
FL077927000Medicaid