Healthcare Provider Details

I. General information

NPI: 1154899763
Provider Name (Legal Business Name): VOLUSIA ENDODONTICS-MAITLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 N ORLANDO AVE STE 203
MAITLAND FL
32751-4465
US

IV. Provider business mailing address

670 N ORLANDO AVE STE 203
MAITLAND FL
32751-4465
US

V. Phone/Fax

Practice location:
  • Phone: 407-581-9515
  • Fax:
Mailing address:
  • Phone: 407-581-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: SUSIE BOBO
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-581-9515