Healthcare Provider Details

I. General information

NPI: 1659011948
Provider Name (Legal Business Name): ADVANTAGE DENTAL ORAL HEALTH CENTER OF FLORIDA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 EGLIN PKWY NE STE 28
FT WALTON BCH FL
32548-4284
US

IV. Provider business mailing address

3322 W END AVE STE 400
NASHVILLE TN
37203-6805
US

V. Phone/Fax

Practice location:
  • Phone: 850-749-6069
  • Fax:
Mailing address:
  • Phone: 629-999-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHERRIE EDMONDSON
Title or Position: SMANAGER, LICENSING & CREDENTIALING
Credential:
Phone: 629-999-5014