Healthcare Provider Details

I. General information

NPI: 1841447190
Provider Name (Legal Business Name): JOSEPH BRENT NOVAK, DMD,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CR 542W
BUSHNELL FL
33513-4515
US

IV. Provider business mailing address

65 CR 542W
BUSHNELL FL
33513-4515
US

V. Phone/Fax

Practice location:
  • Phone: 352-569-0100
  • Fax: 352-569-0213
Mailing address:
  • Phone: 352-569-0100
  • Fax: 352-569-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN17794
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15206
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14246
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16913
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15463
License Number StateFL

VIII. Authorized Official

Name: DR. JOSEPH BRENT NOVAK
Title or Position: PRESIDENT
Credential: DMD
Phone: 352-569-0100