Healthcare Provider Details

I. General information

NPI: 1174888663
Provider Name (Legal Business Name): DENTAL SURGERY SPECIALISTS OF OKEECHOBEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NE 19TH DR
OKEECHOBEE FL
34972-1933
US

IV. Provider business mailing address

113 NE 19TH DR
OKEECHOBEE FL
34972-1933
US

V. Phone/Fax

Practice location:
  • Phone: 863-824-6125
  • Fax:
Mailing address:
  • Phone: 863-824-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN16640
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN17032
License Number StateFL

VIII. Authorized Official

Name: GLEN CASTO
Title or Position: OWNER
Credential: DDS,MDS
Phone: 863-824-6125