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General NPI Number Information
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NPI Number | 1609122357
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Entity Type | Organization
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Legal Business Name | WINTER HAVEN ORAL SURGERY, PA
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Dates
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Enumeration Date | 07/31/2012
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Last Update Date | 08/21/2014
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Provider Practice Location Address
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Address Line | 400 AVENUE K SE SUITE # 14A
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City | WINTER HAVEN
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State | FL
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Zip | 33880-4146
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Country | US
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Telephone | 863-294-7648
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Fax | 863-294-9045
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Provider Business Mailing Address
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Address Line | 400 AVENUE K SE SUITE # 14A
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City | WINTER HAVEN
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State | FL
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Zip | 33880-4146
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Country | US
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Telephone | 863-294-7648
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Fax | 863-294-9045
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. JOSE LUIS LEON RAMIREZ
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Credential | DMD, MD
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Telephone | 863-294-7648
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN18539
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License Number State | FL
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