Healthcare Provider Details

I. General information

NPI: 1194187005
Provider Name (Legal Business Name): EDWIN JOHN SZCZEPANIK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7758 WALLACE RD STE 3
ORLANDO FL
32819-7217
US

IV. Provider business mailing address

7758 WALLACE RD STE 3
ORLANDO FL
32819-7217
US

V. Phone/Fax

Practice location:
  • Phone: 407-352-6888
  • Fax: 407-352-0560
Mailing address:
  • Phone: 407-352-6888
  • Fax: 407-352-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8437
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: EDWIN JOHN SZCZEPANIK
Title or Position: OWNER
Credential: DMD
Phone: 407-352-6888