Healthcare Provider Details

I. General information

NPI: 1013402007
Provider Name (Legal Business Name): PC ENDO SOUTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 JOHNS LAKE RD STE 1
CLERMONT FL
34711-7005
US

IV. Provider business mailing address

1471 JOHNS LAKE RD STE 1
CLERMONT FL
34711-7005
US

V. Phone/Fax

Practice location:
  • Phone: 321-204-6471
  • Fax: 407-674-2539
Mailing address:
  • Phone: 321-204-6471
  • Fax: 407-674-2539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: LINDSAY SMOCK
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 352-404-5550