=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841368974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANDON ENDODONTICS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 02/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 EICHENFELD DRIVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-654-3636
-----------------------------------------------------
Fax | 813-651-4984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 EICHENFELD DRIVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-654-3636
-----------------------------------------------------
Fax | 813-651-4984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL ORRANTIA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 813-654-3636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DN11659
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11659
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------