| Entity Name: | DENTISTRY OF TAVARES, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 Jan 2022 (3 years ago) |
| Document Number: | L22000009592 |
| FEI/EIN Number | 873752797 |
| Address: | 1941 Salk Ave., Tavares, FL, 32778, US |
| Mail Address: | 1941 SALK AVENUE, TAVARES, FL, 32778, US |
| ZIP code: | 32778 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407515174 | 2021-12-10 | 2023-04-25 | 1941 SALK AVE, TAVARES, FL, 327784306, US | 1941 SALK AVE, TAVARES, FL, 327784306, US | |||||||||||||||||||||
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| Phone | +1 352-357-4588 |
| Phone | +1 321-356-5497 |
Authorized person
| Name | DR. CLEMENT JAMES CONTESTABLE |
| Role | DENTIST/OWNER |
| Phone | 3213565497 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 109499200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Contestable Clement J | Agent | 100 S. Eola Dr., ORLANDO, FL, 32801 |
| Name | Role | Address |
|---|---|---|
| MONTIJO IVAN | Manager | 11063 MOBBERLEY CIRCLE, ORLANDO, FL, 32832 |
| CONTESTABLE CLEM | Manager | 100 S. EOLA DR. UNIT #508, ORLANDO, FL, 32801 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-01-19 | 1941 Salk Ave., Tavares, FL 32778 | No data |
| REGISTERED AGENT NAME CHANGED | 2023-01-19 | Contestable, Clement James | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-01-19 | 100 S. Eola Dr., 508, ORLANDO, FL 32801 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2022-07-21 | 1941 Salk Ave., Tavares, FL 32778 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-06 |
| ANNUAL REPORT | 2023-01-19 |
| Florida Limited Liability | 2022-01-05 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
