Healthcare Provider Details

I. General information

NPI: 1154838365
Provider Name (Legal Business Name): TREVISANI ORAL SURGERY ORLANDO PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10967 LAKE UNDERHILL RD STE 144
ORLANDO FL
32825-4456
US

IV. Provider business mailing address

511 WEKIVA COMMONS CIR
APOPKA FL
32712-3645
US

V. Phone/Fax

Practice location:
  • Phone: 407-764-9900
  • Fax: 407-764-9902
Mailing address:
  • Phone: 407-886-2050
  • Fax: 407-886-2117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN13576
License Number StateFL

VIII. Authorized Official

Name: MRS. TAMI VARGAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-886-2050