Provider Demographics
NPI:1982956447
Name:WILLIE B. SHERMAN JR. D.D.S. P.A.
Entity type:Organization
Organization Name:WILLIE B. SHERMAN JR. D.D.S. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-295-0674
Mailing Address - Street 1:3599 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-3419
Mailing Address - Country:US
Mailing Address - Phone:407-295-0674
Mailing Address - Fax:407-295-9693
Practice Address - Street 1:3599 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-3419
Practice Address - Country:US
Practice Address - Phone:407-295-0674
Practice Address - Fax:407-295-9693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073719401Medicaid