=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215200084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORANGE AVENUE DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2012
-----------------------------------------------------
Last Update Date | 02/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2116 S. ORANGE AVE.
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-426-9933
-----------------------------------------------------
Fax | 407-426-9032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2116 S ORANGE AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-3037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-426-9933
-----------------------------------------------------
Fax | 407-426-9032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. NABIL NAGUIB YOUSSEF JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 407-426-9933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | DN16092
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------