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NPI Code Detail

MEDICARE: SORRENTO DENTAL CARE, II, LLC

MEDICARE: SORRENTO DENTAL CARE, II, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistDN18259FL

General Provider Information

NPI Number : 1578941878
Entity Type Code : Organization
Provider Name (Legal Business Name) : SORRENTO DENTAL CARE, II, LLC
Provider Business Mailing Address
First Line : 2350 S HIGHWAY 29
Second Line :
City : CANTONMENT
State : FL
Zip : 32533-8508
Country : US
Telephone Number : 850-968-2106
Fax Number : 850-968-6342
Provider Business Practice Location Address
First Line : 2350 S HIGHWAY 29
Second Line :
City : CANTONMENT
State : FL
Zip : 32533-8508
Country : US
Telephone Number : 850-968-2106
Fax Number : 850-968-6342
Authorized Official
Title or Position : OWNER/ PRESIDENT
Name : DR. CHRISTOPHER MARTIN CAMPUS
Credential : DMD
Telephone Number : 850-968-2106
Provider Enumeration Date : 05/07/2015
Last Update Date : 05/07/2015

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