=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558979484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR LUIS ESTEVEZ DELGADO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2020
-----------------------------------------------------
Last Update Date | 07/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6882 GULFPORT BLVD S
-----------------------------------------------------
City | SOUTH PASADENA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33707-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-384-9655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5335 35TH ST E
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34203-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-225-9954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25213
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------