=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205949799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA A WORMAN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5353 1ST AVE SOUTH SUITE B
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33707-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-321-6911
-----------------------------------------------------
Fax | 727-328-2120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5353 1ST AVE SOUTH SUITE B
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33707-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-321-6911
-----------------------------------------------------
Fax | 727-328-2120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN014398
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------