Healthcare Provider Details

I. General information

NPI: 1770404105
Provider Name (Legal Business Name): MIDWAY PREMIER DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4169 E STATE ROAD 46 STE 1001
SANFORD FL
32771-8666
US

IV. Provider business mailing address

4169 E STATE ROAD 46 STE 1001
SANFORD FL
32771-8666
US

V. Phone/Fax

Practice location:
  • Phone: 321-286-7916
  • Fax:
Mailing address:
  • Phone: 321-286-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ROBERT GAMMONS
Title or Position: PRESIDENT
Credential:
Phone: 321-286-7916