Healthcare Provider Details

I. General information

NPI: 1053499756
Provider Name (Legal Business Name): FLORIDA CRANIOFACIAL INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/18/2024
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 N ARMENIA AVE STE 3
TAMPA FL
33607-6451
US

IV. Provider business mailing address

4200 N ARMENIA AVE STE 3
TAMPA FL
33607-6451
US

V. Phone/Fax

Practice location:
  • Phone: 813-870-6000
  • Fax: 813-870-6015
Mailing address:
  • Phone: 813-870-6000
  • Fax: 813-870-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDN16594
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME88289
License Number StateFL

VIII. Authorized Official

Name: DR. PAT RICALDE
Title or Position: OWNER
Credential: MD, DDS
Phone: 813-870-6000