| Entity Name: | LAKE WORTH FAMILY DENTISTRY, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 28 Aug 2008 (16 years ago) |
| Date of dissolution: | 24 Sep 2021 (3 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 24 Sep 2021 (3 years ago) |
| Document Number: | P08000080034 |
| FEI/EIN Number | 263265947 |
| Mail Address: | 11897 Preservation Lane, Boca Raton, FL, 33498, US |
| Address: | 6427 LAKE WORTH RD, GREENACRES, FL, 33463 |
| ZIP code: | 33463 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1689824153 | 2008-09-22 | 2008-09-22 | 10800 AVENIDA DEL RIO, DELRAY BEACH, FL, 334462444, US | 6427 LAKE WORTH RD STE 102, GREENACRES, FL, 334632900, US | |||||||||||||||||||||||
|
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| Phone | +1 561-649-6446 |
Authorized person
| Name | DR. ILYA STEIN |
| Role | PRESIDENT |
| Phone | 5555555555 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | DN14972 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 070167000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| STEIN ILYA D | Agent | 6427 LAKE WORTH RD, GREENACRES, FL, 33463 |
| Name | Role | Address |
|---|---|---|
| STEIN ILYA D | President | 6427 LAKE WORTH RD, GREENACRES, FL, 33463 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2016-01-22 | 6427 LAKE WORTH RD, GREENACRES, FL 33463 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2010-01-11 | 6427 LAKE WORTH RD, GREENACRES, FL 33463 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2010-01-11 | 6427 LAKE WORTH RD, GREENACRES, FL 33463 | No data |
| REGISTERED AGENT NAME CHANGED | 2009-01-16 | STEIN, ILYA DMD | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J22000477648 | TERMINATED | 1000000934087 | PALM BEACH | 2022-09-23 | 2032-10-12 | $ 1,096.25 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, CORAL SPRINGS SERVICE CENTER, 3301 N UNIVERSITY DR STE 200, CORAL SPRINGS FL330654149 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2020-06-08 |
| ANNUAL REPORT | 2019-03-26 |
| ANNUAL REPORT | 2018-01-15 |
| ANNUAL REPORT | 2017-01-06 |
| ANNUAL REPORT | 2016-01-22 |
| ANNUAL REPORT | 2015-01-12 |
| ANNUAL REPORT | 2014-01-12 |
| ANNUAL REPORT | 2013-01-24 |
| ANNUAL REPORT | 2012-01-07 |
| ANNUAL REPORT | 2011-01-07 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
