Healthcare Provider Details

I. General information

NPI: 1740379460
Provider Name (Legal Business Name): JORGE REYES VICENTE DMD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 S ALAFAYA TRL SUITE #300
ORLANDO FL
32828-8962
US

IV. Provider business mailing address

1549 S ALAFAYA TRL SUITE #300
ORLANDO FL
32828-8962
US

V. Phone/Fax

Practice location:
  • Phone: 407-249-0818
  • Fax: 407-249-0851
Mailing address:
  • Phone: 407-249-0818
  • Fax: 407-249-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16593
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH18736
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: