=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184775421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT W LADLEY D.M.D. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320A W BURLEIGH BLVD
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-742-3383
-----------------------------------------------------
Fax | 352-742-3583
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37918 N COUNTY ROAD 44A
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32736-8329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-357-5976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENDODONTIST
-----------------------------------------------------
Name | DR. ROBERT WILLIAM LADLEY
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 352-742-3383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 9260
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------