Provider Demographics
NPI:1104198282
Name:IMPLANTS, PERIODONTICS & FACIAL REJUVENATION
Entity Type:Organization
Organization Name:IMPLANTS, PERIODONTICS & FACIAL REJUVENATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MERRELL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:813-299-3867
Mailing Address - Street 1:2346 CREEL LANE #101
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544
Mailing Address - Country:US
Mailing Address - Phone:813-299-3867
Mailing Address - Fax:
Practice Address - Street 1:2346 CREEL LN STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-4623
Practice Address - Country:US
Practice Address - Phone:813-299-3867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN012810261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental