Healthcare Provider Details

I. General information

NPI: 1447855903
Provider Name (Legal Business Name): HIRCANIA BENEDICTA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
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

180 MORNING GLORY DR
LAKE MARY FL
32746-6194
US

V. Phone/Fax

Practice location:
  • Phone: 407-673-9111
  • Fax:
Mailing address:
  • Phone: 786-925-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH25190
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: