Provider Demographics
NPI:1760419089
Name:AVILA, JOSE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:M
Last Name:AVILA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:M
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:8806 SHELDON CHASE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-1089
Mailing Address - Country:US
Mailing Address - Phone:813-767-8218
Mailing Address - Fax:
Practice Address - Street 1:41324 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-5111
Practice Address - Country:US
Practice Address - Phone:727-942-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN172061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice