Healthcare Provider Details

I. General information

NPI: 1841368974
Provider Name (Legal Business Name): BRANDON ENDODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 EICHENFELD DRIVE
BRANDON FL
33511
US

IV. Provider business mailing address

625 EICHENFELD DRIVE
BRANDON FL
33511
US

V. Phone/Fax

Practice location:
  • Phone: 813-654-3636
  • Fax: 813-651-4984
Mailing address:
  • Phone: 813-654-3636
  • Fax: 813-651-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11659
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN11659
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL ORRANTIA
Title or Position: PRESIDENT
Credential: DMD
Phone: 813-654-3636