Healthcare Provider Details

I. General information

NPI: 1144812348
Provider Name (Legal Business Name): AMP ORAL AND MAXILLOFACIAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3861 AVALON PARK EAST BLVD
ORLANDO FL
32828-4853
US

IV. Provider business mailing address

10524 MOSS PARK RD STE 204-616
ORLANDO FL
32832-5898
US

V. Phone/Fax

Practice location:
  • Phone: 407-544-0139
  • Fax:
Mailing address:
  • Phone: 678-480-9808
  • Fax:

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. JONATHAN CLINTON ELMORE
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: DDS
Phone: 678-480-9808