=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164170916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IOANNA BORISSOVA ULRICH DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2022
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 3RD ST NW
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33881-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-450-1956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1053 SYLVIA LN
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33613-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-955-2837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN24315
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------