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General NPI Number Information
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NPI Number | 1881137842
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Entity Type | Organization
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Legal Business Name | ADVANCED ORTHODONTICS OF AMERICA, LLC
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Dates
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Enumeration Date | 11/23/2016
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Last Update Date | 11/23/2016
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Provider Practice Location Address
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Address Line | 2202 STATE AVE STE 200
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City | PANAMA CITY
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State | FL
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Zip | 32405-4582
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Country | US
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Telephone | 850-769-2722
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Fax |
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Provider Business Mailing Address
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Address Line | 2202 STATE AVE STE 200
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City | PANAMA CITY
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State | FL
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Zip | 32405-4582
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | LAUREN KOVALESKI
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Credential |
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Telephone | 850-769-2722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN19214
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License Number State | FL
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