Basic Information
| Provider Information | |||||||||
| NPI: | 1902398639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALLAHASSEE ORAL AND MAXILLOFACIAL SURGERY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3665 COOLIDGE CT STE 102 | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323117894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504316725 | ||||||||
| FaxNumber: | 8504316859 | ||||||||
| Practice Location | |||||||||
| Address1: | 3665 COOLIDGE CT STE 102 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323117894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504316725 | ||||||||
| FaxNumber: | 8504316859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2018 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | ORAL AND MAXILLOFACIAL SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 7875566039 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD, MD | ||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.