Healthcare Provider Details

I. General information

NPI: 1053147355
Provider Name (Legal Business Name): DR. NATHALIA VILELA SOUZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DRIVE ROOM D1-19
GAINESVILLE FL
32610-0434
US

IV. Provider business mailing address

714 SW 16TH AVE APT 306
GAINESVILLE FL
32601-8531
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7846
  • Fax:
Mailing address:
  • Phone: 352-682-9920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDRPM2802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: