=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689160434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREVISANI ORAL SURGERY THE VILLAGES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 07/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 N HWY 441 SUITE 302
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-751-5100
-----------------------------------------------------
Fax | 407-886-2117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 N US HIGHWAY 441
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-3001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TAMI VARGAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-886-2050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN13576
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------