Healthcare Provider Details

I. General information

NPI: 1841560265
Provider Name (Legal Business Name): EDGEWATER ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2012
Last Update Date: 01/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 SPRING HILL DR
SPRING HILL FL
34606-4558
US

IV. Provider business mailing address

5305 SPRING HILL DR
SPRING HILL FL
34606-4558
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-7858
  • Fax: 352-688-7816
Mailing address:
  • Phone: 352-688-7858
  • Fax: 352-688-7816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN17788
License Number StateFL

VIII. Authorized Official

Name: HILDE RIORDAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-688-7858