Provider Demographics
NPI:1194764027
Name:DERRICK, ANTHONY CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:CHARLES
Last Name:DERRICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4878
Mailing Address - Country:US
Mailing Address - Phone:407-788-8400
Mailing Address - Fax:407-682-4659
Practice Address - Street 1:2633 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4878
Practice Address - Country:US
Practice Address - Phone:407-788-8400
Practice Address - Fax:407-682-4659
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0005472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist