Healthcare Provider Details

I. General information

NPI: 1295028223
Provider Name (Legal Business Name): TOWNCARE DENTAL OF WINTER PARK, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 W FAIRBANKS AVE
WINTER PARK FL
32789-4605
US

IV. Provider business mailing address

13195 SW 134TH ST FL 2
MIAMI FL
33186-4461
US

V. Phone/Fax

Practice location:
  • Phone: 407-629-1804
  • Fax:
Mailing address:
  • Phone: 305-274-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: PROVIDER RELATIONS SPECIALIST
Credential:
Phone: 305-274-2499