Provider Demographics
NPI:1770859365
Name:TREVISANI ORAL SURGERY
Entity type:Organization
Organization Name:TREVISANI ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:EAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-886-2050
Mailing Address - Street 1:4151 HUNTERS PARK LN
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-3617
Mailing Address - Country:US
Mailing Address - Phone:407-764-9500
Mailing Address - Fax:407-764-9502
Practice Address - Street 1:4151 HUNTERS PARK LN
Practice Address - Street 2:SUITE 140
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-3617
Practice Address - Country:US
Practice Address - Phone:407-764-9500
Practice Address - Fax:407-764-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13576261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery