Provider Demographics
NPI:1578941878
Name:SORRENTO DENTAL CARE, II, LLC
Entity Type:Organization
Organization Name:SORRENTO DENTAL CARE, II, LLC
Other - Org Name:AGGIE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:CAMPUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-968-2106
Mailing Address - Street 1:2350 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-8508
Mailing Address - Country:US
Mailing Address - Phone:850-968-2106
Mailing Address - Fax:850-968-6342
Practice Address - Street 1:2350 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-8508
Practice Address - Country:US
Practice Address - Phone:850-968-2106
Practice Address - Fax:850-968-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty