Provider Demographics
NPI:1275928905
Name:OAKPORT DENTAL SANFORD PLLC
Entity Type:Organization
Organization Name:OAKPORT DENTAL SANFORD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-323-5340
Mailing Address - Street 1:2421 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-4269
Mailing Address - Country:US
Mailing Address - Phone:407-323-5340
Mailing Address - Fax:407-322-9136
Practice Address - Street 1:2421 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-4269
Practice Address - Country:US
Practice Address - Phone:407-323-5340
Practice Address - Fax:407-322-9136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty