=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831043868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA PERIODONTAL SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2026
-----------------------------------------------------
Last Update Date | 02/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12161 COUNTY ROAD 103 STE 101
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34484-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-259-6799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12161 COUNTY ROAD 103 STE 101
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34484-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-259-6799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | JENNIFER HERITAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-805-4516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------