Healthcare Provider Details

I. General information

NPI: 1972664779
Provider Name (Legal Business Name): DEBORAH ROYSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 W WATERS AVE
TAMPA FL
33634-1140
US

IV. Provider business mailing address

1770 N WICKHAM RD
MELBOURNE FL
32935-8122
US

V. Phone/Fax

Practice location:
  • Phone: 813-886-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14080
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: