Provider Demographics
NPI:1609122357
Name:WINTER HAVEN ORAL SURGERY, PA
Entity Type:Organization
Organization Name:WINTER HAVEN ORAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE LUIS
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:863-294-7648
Mailing Address - Street 1:400 AVENUE K SE
Mailing Address - Street 2:SUITE # 14A
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4146
Mailing Address - Country:US
Mailing Address - Phone:863-294-7648
Mailing Address - Fax:863-294-9045
Practice Address - Street 1:400 AVENUE K SE
Practice Address - Street 2:SUITE # 14A
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4146
Practice Address - Country:US
Practice Address - Phone:863-294-7648
Practice Address - Fax:863-294-9045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN185391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty