Healthcare Provider Details

I. General information

NPI: 1043310204
Provider Name (Legal Business Name): DWIGHT E. SANJUAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6532 GUNN HWY
TAMPA FL
33625-4022
US

IV. Provider business mailing address

6532 GUNN HWY
TAMPA FL
33625-4022
US

V. Phone/Fax

Practice location:
  • Phone: 813-969-0999
  • Fax: 813-968-8875
Mailing address:
  • Phone: 813-969-0999
  • Fax: 813-968-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN15486
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: