=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700503885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES E MIDKIFF, DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2022
-----------------------------------------------------
Last Update Date | 10/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 S MAITLAND AVE STE 2
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-5674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-647-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 S MAITLAND AVE STE 2
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-5674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-647-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING LEAD
-----------------------------------------------------
Name | JENNY GARCIA-ROCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------