| Entity Name: | ORANGE PARK DENTISTRY, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 14 Oct 2021 (3 years ago) |
| Document Number: | L21000448754 |
| FEI/EIN Number | 87-3062448 |
| Mail Address: | 3221 CONWAY RD, STE D, ORLANDO, FL, 32812, US |
| Address: | 784 Blanding Blvd, Orange Park, FL, 32065, US |
| ZIP code: | 32065 |
| County: | Clay |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1780342352 | 2021-12-01 | 2021-12-01 | 784 BLANDING BLVD STE 110, ORANGE PARK, FL, 320657724, US | 784 BLANDING BLVD STE 110, ORANGE PARK, FL, 320657724, US | |||||||||||||||||||||||||
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| Phone | +1 904-272-2438 |
Authorized person
| Name | DR. PETER KELLY |
| Role | OWNER |
| Phone | 9042722438 |
Taxonomy
| Taxonomy Code | 261QD0000X - Dental Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | STATE LICENSE |
| Number | DN19430 |
| State | FL |
| Issuer | STATE LICENSE |
| Number | DN26279 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ROBINSON MATTHEW | Agent | 3221 CONWAY RD, ORLANDO, FL, 32812 |
| Name | Role | Address |
|---|---|---|
| KELLY PETER | Managing Member | 3221 CONWAY RD STE D, ORLANDO, FL, 32812 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-01-30 | 784 Blanding Blvd, 110, Orange Park, FL 32065 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-15 |
| ANNUAL REPORT | 2023-02-24 |
| ANNUAL REPORT | 2022-01-30 |
| Florida Limited Liability | 2021-10-14 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
