Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DN10720 | FL |
NPI | 1013092170 |
---|---|
Provider Name | Dr. Joseph James Ceravolo |
First Address | Wellington, FL 33414 |
Second Address | Wellington, FL 33414-6138 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2006 |
Last Update Date | 08/07/2007 |