Healthcare Provider Details

I. General information

NPI: 1114621513
Provider Name (Legal Business Name): GRAND OAKS DENTAL CARE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SE 17TH ST
OCALA FL
34471-5519
US

IV. Provider business mailing address

2710 SE 17TH ST
OCALA FL
34471-5519
US

V. Phone/Fax

Practice location:
  • Phone: 352-820-4926
  • Fax:
Mailing address:
  • Phone: 352-820-4926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SIMON AMIR
Title or Position: OWNER
Credential: DMD
Phone: 352-682-7640