Healthcare Provider Details

I. General information

NPI: 1740568187
Provider Name (Legal Business Name): HOUSE OF COSMETIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 FORTUNE RD
KISSIMMEE FL
34744-3993
US

IV. Provider business mailing address

2324 FORTUNE RD
KISSIMMEE FL
34744-3993
US

V. Phone/Fax

Practice location:
  • Phone: 407-348-2002
  • Fax: 407-348-2009
Mailing address:
  • Phone: 407-348-2002
  • Fax: 407-348-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16387
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16586
License Number StateFL

VIII. Authorized Official

Name: MS. LINA SEGURA
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-348-2002