Healthcare Provider Details

I. General information

NPI: 1083051924
Provider Name (Legal Business Name): LUDMILS ANTONOS JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7352 STONEROCK CIR
ORLANDO FL
32819-8000
US

IV. Provider business mailing address

13863 FOX GLOVE ST
WINTER GARDEN FL
34787-4674
US

V. Phone/Fax

Practice location:
  • Phone: 407-351-0575
  • Fax: 407-363-6945
Mailing address:
  • Phone: 407-435-4535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: