Healthcare Provider Details

I. General information

NPI: 1285237149
Provider Name (Legal Business Name): BRONSA TAIMARA SEMIDEY LUGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6432 W COLONIAL DR
ORLANDO FL
32818-6820
US

IV. Provider business mailing address

4010 SANTA MARIA DR
KISSIMMEE FL
34741-1563
US

V. Phone/Fax

Practice location:
  • Phone: 407-293-9573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH27984
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: