| Entity Name: | CHURCHILL PEDIATRIC DENTISTRY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 08 Oct 2013 (11 years ago) |
| Date of dissolution: | 28 Sep 2018 (6 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 28 Sep 2018 (6 years ago) |
| Document Number: | L13000141891 |
| FEI/EIN Number | 46-3826187 |
| Address: | 1397 W Lakeshore Dr, Clermont, FL, 34711, US |
| Mail Address: | 1397 W Lakeshore Dr, Clermont, FL, 34711, US |
| ZIP code: | 34711 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1487081352 | 2013-10-08 | 2013-10-08 | 1371 SW 43RD PL, OCALA, FL, 344717501, US | 1371 SW 43RD PL, OCALA, FL, 344717501, US | |||||||||||||||||||||||
|
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| Phone | +1 352-274-9731 |
Authorized person
| Name | DR. REBECCA J TARVER |
| Role | OWNER |
| Phone | 3522749731 |
Taxonomy
| Taxonomy Code | 1223G0001X - General Practice Dentistry |
| License Number | DN19038 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 002880200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| TARVER REBECCA J | Agent | 1397 W Lakeshore Dr, Clermont, FL, 34711 |
| Name | Role | Address |
|---|---|---|
| TARVER REBECCA J | Manager | 1397 W Lakeshore Dr, Clermont, FL, 34711 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-04-28 | 1397 W Lakeshore Dr, Clermont, FL 34711 | No data |
| CHANGE OF MAILING ADDRESS | 2016-04-28 | 1397 W Lakeshore Dr, Clermont, FL 34711 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-04-28 | 1397 W Lakeshore Dr, Clermont, FL 34711 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2017-03-21 |
| ANNUAL REPORT | 2016-04-28 |
| ANNUAL REPORT | 2015-04-23 |
| ANNUAL REPORT | 2014-04-15 |
| Florida Limited Liability | 2013-10-08 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
