Organization
IMPERIAL BOULEVARD MANAGEMENT,LLC
Active
Other names
Lakeland Pediatirc Dental Care
Organization subpart
No
Provider details
NPI number
Authorized official
ANGEL NICHOLS (TURSTEE)
(863) 644-4739
Entity
Organization
Contact information
Practice address
225 IMPERIAL BLVD, LAKELAND, FL 33803-4612
(863) 644-4739
(863) 644-1333
Mailing address
225 IMPERIAL BLVD, LAKELAND, FL 33803-4612
(863) 644-4739
(863) 644-1333
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
1190925
FL
Other
Enumeration date
08/07/2008
Last updated
08/07/2008
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