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General NPI Number Information
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NPI Number | 1114291002
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Entity Type | Organization
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Legal Business Name | IMPLANTIS ORAL & FACIAL SURGERY, PA
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Dates
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Enumeration Date | 02/24/2012
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Last Update Date | 02/24/2012
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Provider Practice Location Address
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Address Line | 3940 SWIFT RD
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City | SARASOTA
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State | FL
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Zip | 34231-6541
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Country | US
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Telephone | 941-923-0033
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Fax | 941-922-4621
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Provider Business Mailing Address
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Address Line | 3940 SWIFT RD
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City | SARASOTA
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State | FL
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Zip | 34231-6541
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Country | US
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Telephone | 941-923-0033
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Fax | 941-922-4621
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Authorized Official
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Title or Position | PRESIDENT
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Name | GARY RASKA
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Credential | DMD
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Telephone | 941-923-0033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN18583
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License Number State | FL
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