Provider Demographics
NPI:1699901165
Name:ATA, JILL EDWARDS (DMD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:EDWARDS
Last Name:ATA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3192 S JOHN YOUNG PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-8814
Mailing Address - Country:US
Mailing Address - Phone:407-870-5151
Mailing Address - Fax:407-870-2556
Practice Address - Street 1:3192 S JOHN YOUNG PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-8814
Practice Address - Country:US
Practice Address - Phone:407-870-5151
Practice Address - Fax:407-870-2556
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18675122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist