Healthcare Provider Details

I. General information

NPI: 1942689807
Provider Name (Legal Business Name): PC ENDO SOUTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
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: 352-404-5550
  • Fax:
Mailing address:
  • Phone: 352-404-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: AMBER MAE PERRY
Title or Position: CFO
Credential:
Phone: 352-404-5550