=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982070215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULISES A GUZMAN DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2015
-----------------------------------------------------
Last Update Date | 08/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6907 W WATERS AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33634-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-887-5555
-----------------------------------------------------
Fax | 813-887-5556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6907 W WATERS AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33634-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-887-5555
-----------------------------------------------------
Fax | 813-887-5556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ULISES ANTONIO GUZMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 813-887-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN13659
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------