Healthcare Provider Details

I. General information

NPI: 1306230545
Provider Name (Legal Business Name): ORAL SURGERY ASSOCIATES OF CENTRAL FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7651 ASHLEY PARK CT SUITE 406B
ORLANDO FL
32835-6114
US

IV. Provider business mailing address

7651 ASHLEY PARK CT SUITE 406B
ORLANDO FL
32835-6114
US

V. Phone/Fax

Practice location:
  • Phone: 407-294-3300
  • Fax: 407-297-7417
Mailing address:
  • Phone: 407-294-3300
  • Fax: 407-297-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDN11672
License Number StateFL

VIII. Authorized Official

Name: DOUGLAS KENT POWELSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 407-294-3300