Healthcare Provider Details

I. General information

NPI: 1033533203
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATES OF ORLANDO, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2014
Last Update Date: 02/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 LEE RD STE A
WINTER PARK FL
32789-1871
US

IV. Provider business mailing address

8773 TALLY HO LN
ROYAL PALM BEACH FL
33411-4541
US

V. Phone/Fax

Practice location:
  • Phone: 407-647-2131
  • Fax: 407-645-5161
Mailing address:
  • Phone: 561-543-6782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN15891
License Number StateFL

VIII. Authorized Official

Name: DR. SANG Y SHIN
Title or Position: ENDODONTIST/ OWNER
Credential: DMD
Phone: 561-543-6782