Healthcare Provider Details

I. General information

NPI: 1447702071
Provider Name (Legal Business Name): SONDRA L AVANT DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 DUNLAWTON AVE STE 105
PORT ORANGE FL
32127-4237
US

IV. Provider business mailing address

731 DUNLAWTON AVE STE 105
PORT ORANGE FL
32127-4237
US

V. Phone/Fax

Practice location:
  • Phone: 386-304-4620
  • Fax: 386-304-4619
Mailing address:
  • Phone: 386-304-4620
  • Fax: 386-304-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN13606
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN13606
License Number StateFL

VIII. Authorized Official

Name: DR. SONDRA AVANT
Title or Position: OWNER
Credential: DDS MS
Phone: 386-304-4620