=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912099813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY E HERTZ D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8801 COMMODITY CIR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-9053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-248-0100
-----------------------------------------------------
Fax | 407-248-8364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8801 COMMODITY CIRCLE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-9053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-248-0100
-----------------------------------------------------
Fax | 407-248-8364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 16360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------