Provider Demographics
NPI:1154899763
Name:VOLUSIA ENDODONTICS-MAITLAND
Entity type:Organization
Organization Name:VOLUSIA ENDODONTICS-MAITLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-581-9515
Mailing Address - Street 1:670 N ORLANDO AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4465
Mailing Address - Country:US
Mailing Address - Phone:407-581-9515
Mailing Address - Fax:
Practice Address - Street 1:670 N ORLANDO AVE STE 203
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4465
Practice Address - Country:US
Practice Address - Phone:407-581-9515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty