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General NPI Number Information
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NPI Number | 1114025236
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Entity Type | Organization
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Legal Business Name | ENDODONTICS
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 609 N CHARLES RICHARD BEALL BLVD STE 105
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City | DEBARY
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State | FL
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Zip | 32713-2218
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Country | US
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Telephone | 386-775-2025
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Fax |
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Provider Business Mailing Address
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Address Line | 609 N CHARLES RICHARD BEALL BLVD STE 105
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City | DEBARY
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State | FL
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Zip | 32713-2218
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Country | US
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Telephone | 386-775-2025
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL EDWARD DEGROOD
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Credential |
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Telephone | 386-775-2025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 0012305
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License Number State | FL
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