Healthcare Provider Details

I. General information

NPI: 1205812583
Provider Name (Legal Business Name): ERNESTO JOSE TORRES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114 96 DENTAL SQUADRON
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

4241 LOST HORSE CIR
NICEVILLE FL
32578-7128
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8582
  • Fax:
Mailing address:
  • Phone: 850-279-3291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN21959
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1078
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: