Provider Demographics
NPI:1114462496
Name:CARDINAL ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:CARDINAL ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEER
Authorized Official - Middle Name:N
Authorized Official - Last Name:HATE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:386-756-2580
Mailing Address - Street 1:870 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9274
Mailing Address - Country:US
Mailing Address - Phone:386-756-2580
Mailing Address - Fax:386-756-2333
Practice Address - Street 1:870 DUNLAWTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9274
Practice Address - Country:US
Practice Address - Phone:386-756-2580
Practice Address - Fax:386-756-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67275OtherBLUE CROSS BLUE SHIELD