Provider Demographics
NPI:1235471590
Name:LAND O LAKES ORAL MAXILLOFACIAL & IMPLANT SURGERY
Entity Type:Organization
Organization Name:LAND O LAKES ORAL MAXILLOFACIAL & IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-528-8999
Mailing Address - Street 1:5420 LAND O LAKES BLVD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-3401
Mailing Address - Country:US
Mailing Address - Phone:813-528-8999
Mailing Address - Fax:813-528-8997
Practice Address - Street 1:5420 LAND O LAKES BLVD
Practice Address - Street 2:SUITE #103
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-3401
Practice Address - Country:US
Practice Address - Phone:813-528-8999
Practice Address - Fax:813-528-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty