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2127 W State Road 434 Longwood FL 32779-4983 | |
| (407) 332-6060 | |
| (407) 332-8190 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 2127 W State Road 434, Longwood, Florida |
| Authorized Official Name and Position | All Credentialing (INS COOD) |
| Authorized Official Contact | 2175402100 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2127 W State Road 434 Longwood FL 32779-4983 Ph: (407) 332-6060 | 2127 W State Road 434 Longwood FL 32779-4983 Ph: (407) 332-6060 |
| NPI Number | 1851503577 |
|---|---|
| Provider Enumeration Date | 05/04/2007 |
| Last Update Date | 10/19/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851503577 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
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