Healthcare Provider Details

I. General information

NPI: 1124402912
Provider Name (Legal Business Name): HOFFMAN ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 KINGSLEY AVE STE B
ORANGE PARK FL
32073-4590
US

IV. Provider business mailing address

1406 KINGSLEY AVE STE B
ORANGE PARK FL
32073-4590
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-4519
  • Fax: 904-264-4510
Mailing address:
  • Phone: 904-264-4519
  • Fax: 904-264-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20979
License Number StateFL

VIII. Authorized Official

Name: DEREK HOFFMAN
Title or Position: PRESIDENT
Credential: D.M.D., M.S.
Phone: 904-264-4519