Provider Demographics
NPI:1144812348
Name:AMP ORAL AND MAXILLOFACIAL SURGERY, PA
Entity type:Organization
Organization Name:AMP ORAL AND MAXILLOFACIAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-480-9808
Mailing Address - Street 1:10524 MOSS PARK RD STE 204-616
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5898
Mailing Address - Country:US
Mailing Address - Phone:678-480-9808
Mailing Address - Fax:
Practice Address - Street 1:3861 AVALON PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4853
Practice Address - Country:US
Practice Address - Phone:407-544-0139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty