Provider Demographics
NPI:1669111902
Name:FLORIDA MAXILLOFACIAL AND RECONSTRUCTIVE SURGERY PA
Entity type:Organization
Organization Name:FLORIDA MAXILLOFACIAL AND RECONSTRUCTIVE SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-463-9588
Mailing Address - Street 1:PO BOX 1112
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-1112
Mailing Address - Country:US
Mailing Address - Phone:407-463-9588
Mailing Address - Fax:949-798-7844
Practice Address - Street 1:7350 SANDLAKE COMMONS BLVD STE 2212A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8031
Practice Address - Country:US
Practice Address - Phone:407-463-9588
Practice Address - Fax:949-798-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty