Healthcare Provider Details

I. General information

NPI: 1174376677
Provider Name (Legal Business Name): ROBERTO DANIEL LARICCHIA SUPPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 ALAFAYA TRL STE 180
OVIEDO FL
32765-9419
US

IV. Provider business mailing address

4250 ALAFAYA TRL STE 180
OVIEDO FL
32765-9419
US

V. Phone/Fax

Practice location:
  • Phone: 407-359-1960
  • Fax:
Mailing address:
  • Phone: 407-359-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES.004728
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN32241
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: