Provider Demographics
NPI:1053499756
Name:FLORIDA CRANIOFACIAL INSTITUTE
Entity Type:Organization
Organization Name:FLORIDA CRANIOFACIAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICALDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:813-870-6000
Mailing Address - Street 1:4200 N ARMENIA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6451
Mailing Address - Country:US
Mailing Address - Phone:813-870-6000
Mailing Address - Fax:813-870-6015
Practice Address - Street 1:4200 N ARMENIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6451
Practice Address - Country:US
Practice Address - Phone:813-870-6000
Practice Address - Fax:813-870-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16594174400000X
FLME88289204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty