Provider Demographics
NPI:1538399324
Name:OBT DENTAL SPA
Entity type:Organization
Organization Name:OBT DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:OLMOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-857-8585
Mailing Address - Street 1:9753 S ORANGE BLOSSOM TRL STE 105
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-8998
Mailing Address - Country:US
Mailing Address - Phone:407-857-8585
Mailing Address - Fax:407-857-8448
Practice Address - Street 1:9753 S ORANGE BLOSSOM TRL STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8998
Practice Address - Country:US
Practice Address - Phone:407-857-8585
Practice Address - Fax:407-857-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN165861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty