Healthcare Provider Details

I. General information

NPI: 1699041285
Provider Name (Legal Business Name): TREVISANI ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 W BROADWAY ST SUITE 204
OVIEDO FL
32765-6456
US

IV. Provider business mailing address

1410 W BROADWAY ST SUITE 204
OVIEDO FL
32765-6456
US

V. Phone/Fax

Practice location:
  • Phone: 407-366-2243
  • Fax: 407-359-3343
Mailing address:
  • Phone: 407-366-2243
  • Fax: 407-359-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDN13576
License Number StateFL

VIII. Authorized Official

Name: MRS. TAMMY EAGLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-886-2050