=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104066448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE VIANA PAIVA JR. D.D.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2009
-----------------------------------------------------
Last Update Date | 04/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2309A SAINT ANDREWS BLVD
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-763-5858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2309A SAINT ANDREWS BLVD
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-763-5858
-----------------------------------------------------
Fax | 850-763-7125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DN18971
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN18971
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------