=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336459064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL SPECIALISTS OF CENTRAL FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2010
-----------------------------------------------------
Last Update Date | 10/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 MAGNOLIA AVE
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-453-7750
-----------------------------------------------------
Fax | 321-453-4966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 MAGNOLIA AVE
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-453-7750
-----------------------------------------------------
Fax | 321-453-4966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JONATHAN OUELLETTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-453-7750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN19069
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH17841
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN19187
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------