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General NPI Number Information
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NPI Number | 1053687640
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Entity Type | Organization
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Legal Business Name | TREVISANI ORAL SURGERY
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Dates
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Enumeration Date | 03/28/2012
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Last Update Date | 03/28/2012
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Provider Practice Location Address
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Address Line | 2574 S VOLUSIA AVE
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City | ORANGE CITY
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State | FL
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Zip | 32763-9123
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Country | US
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Telephone | 386-774-2999
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Fax | 386-774-4922
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Provider Business Mailing Address
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Address Line | 2574 S VOLUSIA AVE
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City | ORANGE CITY
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State | FL
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Zip | 32763-9123
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Country | US
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Telephone | 386-774-2999
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Fax | 386-774-4922
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. TAMMY EAGLE
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Credential |
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Telephone | 407-886-2050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | DN13576
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License Number State | FL
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