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General NPI Number Information
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NPI Number | 1114462496
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Entity Type | Organization
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Legal Business Name | CARDINAL ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
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Dates
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Enumeration Date | 12/22/2016
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Last Update Date | 12/22/2016
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Provider Practice Location Address
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Address Line | 870 DUNLAWTON AVE SUITE 210
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City | PORT ORANGE
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State | FL
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Zip | 32127-9274
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Country | US
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Telephone | 386-756-2580
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Fax | 386-756-2333
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Provider Business Mailing Address
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Address Line | 870 DUNLAWTON AVE SUITE 210
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City | PORT ORANGE
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State | FL
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Zip | 32127-9274
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Country | US
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Telephone | 386-756-2580
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Fax | 386-756-2333
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Authorized Official
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Title or Position | OWNER
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Name | SAMEER N. HATE
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Credential | DMD, MS
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Telephone | 386-756-2580
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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 | DN15831
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License Number State | FL
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