Healthcare Provider Details

I. General information

NPI: 1124225560
Provider Name (Legal Business Name): ESTHER SEBUM OH DDS, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD DEPARTMENT OF ORAL MAXILLOFACIAL SURGERY
GAINESVILLE FL
32610-0416
US

IV. Provider business mailing address

1600 SW ARCHER RD P.O. BOX 100416
GAINESVILLE FL
32610-0416
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6750
  • Fax: 352-392-7609
Mailing address:
  • Phone: 352-273-6750
  • Fax: 352-392-7609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT588
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDT588
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101248090
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: