Healthcare Provider Details

I. General information

NPI: 1548790157
Provider Name (Legal Business Name): PAULA ANDREA GRISALES CANO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2063 ALOMA AVE STE 203
WINTER PARK FL
32792-3319
US

IV. Provider business mailing address

1312 BOB CAT CT
APOPKA FL
32712-3852
US

V. Phone/Fax

Practice location:
  • Phone: 407-673-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: