Provider Demographics
NPI:1952866600
Name:INSTITUTE FOR THE TREATMENT OF CRANIOFACIAL PAIN, PA
Entity Type:Organization
Organization Name:INSTITUTE FOR THE TREATMENT OF CRANIOFACIAL PAIN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FUSELIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-963-0553
Mailing Address - Street 1:1203 PRESERVE POINT DR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5939
Mailing Address - Country:US
Mailing Address - Phone:407-963-0553
Mailing Address - Fax:
Practice Address - Street 1:2122 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6047
Practice Address - Country:US
Practice Address - Phone:407-963-0553
Practice Address - Fax:407-637-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-07
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1700859063OtherOMS
FL1265405518OtherOMS