Provider Demographics
NPI:1649432881
Name:COSMETIC AND RESTORATIVE DENTISTRY OF LAKE MARY
Entity type:Organization
Organization Name:COSMETIC AND RESTORATIVE DENTISTRY OF LAKE MARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAPUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-251-5100
Mailing Address - Street 1:737 STIRLING CENTER PL
Mailing Address - Street 2:SUITE 1011
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4856
Mailing Address - Country:US
Mailing Address - Phone:407-805-8808
Mailing Address - Fax:
Practice Address - Street 1:737 STIRLING CENTER PL
Practice Address - Street 2:SUITE 1011
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4856
Practice Address - Country:US
Practice Address - Phone:407-805-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN130681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty