Healthcare Provider Details

I. General information

NPI: 1881068559
Provider Name (Legal Business Name): INNOVATIVE DENTAL & ORTHODONTICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 12/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 W. COUNTY RD 419 SUITE 1010
OVIEDO FL
32765
US

IV. Provider business mailing address

1884 W. COUNTY RD 419 SUITE 1010
OVIEDO FL
32765
US

V. Phone/Fax

Practice location:
  • Phone: 407-797-6940
  • Fax:
Mailing address:
  • Phone: 407-797-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN18557
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN18706
License Number StateFL

VIII. Authorized Official

Name: DR. AMIT KAMAT
Title or Position: DENTIST
Credential: D.M.D.
Phone: 813-528-6955