Provider Demographics
NPI:1124402912
Name:HOFFMAN ORTHODONTICS PA
Entity Type:Organization
Organization Name:HOFFMAN ORTHODONTICS PA
Other - Org Name:PEDEN & HOFFMAN ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:904-264-4519
Mailing Address - Street 1:1406 KINGSLEY AVE
Mailing Address - Street 2:STE B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4590
Mailing Address - Country:US
Mailing Address - Phone:904-264-4519
Mailing Address - Fax:904-264-4510
Practice Address - Street 1:1406 KINGSLEY AVE
Practice Address - Street 2:STE B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4590
Practice Address - Country:US
Practice Address - Phone:904-264-4519
Practice Address - Fax:904-264-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL209791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty