Provider Demographics
NPI:1689160434
Name:TREVISANI ORAL SURGERY THE VILLAGES
Entity Type:Organization
Organization Name:TREVISANI ORAL SURGERY THE VILLAGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-886-2050
Mailing Address - Street 1:929 N US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 N HWY 441
Practice Address - Street 2:SUITE 302
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-751-5100
Practice Address - Fax:407-886-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN135761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty