Provider Demographics
NPI:1659638484
Name:ORLANDO ENDODONTIC SPECIALISTS SOUTH
Entity Type:Organization
Organization Name:ORLANDO ENDODONTIC SPECIALISTS SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE FRONT DESK
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-423-7667
Mailing Address - Street 1:1956 E OSCEOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-8626
Mailing Address - Country:US
Mailing Address - Phone:407-581-9500
Mailing Address - Fax:
Practice Address - Street 1:610 N MILLS AVE
Practice Address - Street 2:210
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-7119
Practice Address - Country:US
Practice Address - Phone:407-423-7667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORLANDO ENDODONTIC SPECIALISTS SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143841223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty