| Entity Name: | PROVIDENCE DENTAL LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 05 Apr 2017 (8 years ago) |
| Date of dissolution: | 25 Sep 2020 (4 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2020 (4 years ago) |
| Document Number: | L17000076217 |
| FEI/EIN Number | 61-1843652 |
| Address: | 4501 S. SEMORAN BLVD., ORLANDO, FL, 32822 |
| Mail Address: | 4501 S. SEMORAN BLVD., ORLANDO, FL, 32822 |
| ZIP code: | 32822 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407330145 | 2018-09-19 | 2018-09-19 | 12450 E. COLONIAL DRIVE SUITE 124, ORLANDO, FL, 32826, US | 12450 E. COLONIAL DRIVE SUITE 124, ORLANDO, FL, 32826, US | |||||||||||||||||||||
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| Phone | +1 407-635-0704 |
| Fax | 4072860439 |
Authorized person
| Name | NADIA KAHOOK |
| Role | CREDENTIALING CONSULTANT |
| Phone | 9544465797 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | PENDING |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Morales Herman | Agent | 4501 S. SEMORAN BLVD., ORLANDO, FL, 32822 |
| Name | Role | Address |
|---|---|---|
| MORALES HERMAN | Manager | 4501 S SEMORAN BLVD, ORLANDO, FL, 32822 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| REINSTATEMENT | 2018-10-12 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2018-10-12 | Morales, Herman | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-10-12 | 4501 S. SEMORAN BLVD., ORLANDO, FL 32822 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2019-05-01 |
| REINSTATEMENT | 2018-10-12 |
| Florida Limited Liability | 2017-04-05 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
