Basic Information
| Provider Information | |||||||||
| NPI: | 1679636559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDREW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 N ORANGE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328051612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074281672 | ||||||||
| FaxNumber: | 4074818638 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 N ORANGE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328051612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074281672 | ||||||||
| FaxNumber: | 4074818638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH 10639 | FL | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | RDH | 01 | FL | REGISTERED DENTAL HIGIENI | OTHER |