Healthcare Provider Details

I. General information

NPI: 1558979484
Provider Name (Legal Business Name): OMAR LUIS ESTEVEZ DELGADO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6882 GULFPORT BLVD S
SOUTH PASADENA FL
33707-2108
US

IV. Provider business mailing address

5335 35TH ST E
BRADENTON FL
34203-5203
US

V. Phone/Fax

Practice location:
  • Phone: 727-384-9655
  • Fax:
Mailing address:
  • Phone: 941-225-9954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: