Healthcare Provider Details

I. General information

NPI: 1740960830
Provider Name (Legal Business Name): SANDRA SHAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 S HIAWASSEE RD STE 135
ORLANDO FL
32835-6439
US

IV. Provider business mailing address

1306 SHADOW PATH DR
PORT ORANGE FL
32128-5510
US

V. Phone/Fax

Practice location:
  • Phone: 407-293-8324
  • Fax:
Mailing address:
  • Phone: 386-334-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN28130
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: