Healthcare Provider Details

I. General information

NPI: 1114462496
Provider Name (Legal Business Name): CARDINAL ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2016
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 DUNLAWTON AVE SUITE 210
PORT ORANGE FL
32127-9274
US

IV. Provider business mailing address

870 DUNLAWTON AVE SUITE 210
PORT ORANGE FL
32127-9274
US

V. Phone/Fax

Practice location:
  • Phone: 386-756-2580
  • Fax: 386-756-2333
Mailing address:
  • Phone: 386-756-2580
  • Fax: 386-756-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15831
License Number StateFL

VIII. Authorized Official

Name: SAMEER N. HATE
Title or Position: OWNER
Credential: DMD, MS
Phone: 386-756-2580