Healthcare Provider Details

I. General information

NPI: 1053365338
Provider Name (Legal Business Name): CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MILLS AVE SUITE 100
ORLANDO FL
32803-7119
US

IV. Provider business mailing address

610 N MILLS AVE SUITE 100
ORLANDO FL
32803-7103
US

V. Phone/Fax

Practice location:
  • Phone: 407-843-2261
  • Fax: 407-841-0247
Mailing address:
  • Phone: 407-843-2261
  • Fax: 407-841-0247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. WILBUR M DAVIS JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 407-843-2261