Provider Demographics
NPI:1821471038
Name:WATERFORD CHASE DENTAL
Entity Type:Organization
Organization Name:WATERFORD CHASE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ENEA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIFSHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-674-6890
Mailing Address - Street 1:801 WOODBURY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4514
Mailing Address - Country:US
Mailing Address - Phone:407-674-6890
Mailing Address - Fax:407-674-6891
Practice Address - Street 1:801 WOODBURY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4514
Practice Address - Country:US
Practice Address - Phone:407-674-6890
Practice Address - Fax:407-674-6891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19721261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental