=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841577095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA SNORING & APNEA SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2011
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 W GRANADA BLVD STE C-2
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-9485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-675-6769
-----------------------------------------------------
Fax | 386-675-6770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 W GRANADA BLVD STE C-2
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-9485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-675-6769
-----------------------------------------------------
Fax | 386-675-6770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELSA WITTBOLD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 386-675-6769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN 18198
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------