Healthcare Provider Details

I. General information

NPI: 1982225132
Provider Name (Legal Business Name): LAKE FOREST ENDODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5264 W STATE ROAD 46 UNIT C4
SANFORD FL
32771
US

IV. Provider business mailing address

610 N MILLS AVE STE 210
ORLANDO FL
32803
US

V. Phone/Fax

Practice location:
  • Phone: 407-577-3636
  • Fax: 407-317-4099
Mailing address:
  • Phone: 407-423-7667
  • Fax: 407-425-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY J TEMPLE
Title or Position: PRESIDENT
Credential: DMD
Phone: 407-423-7667