Healthcare Provider Details

I. General information

NPI: 1023539699
Provider Name (Legal Business Name): WALMIR BALDOCCHI DA COSTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2017
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E ORANGE AVE
EUSTIS FL
32726-4343
US

IV. Provider business mailing address

1340 E ORANGE AVE
EUSTIS FL
32726-4343
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5440
  • Fax:
Mailing address:
  • Phone: 352-333-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN22582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: