Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DN25811 | FL |
NPI | 1114302825 |
---|---|
Provider Name | Dr. Justin Vice |
First Address | Tampa, FL 33625-4022 |
Second Address | Tampa, FL 33625-4022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2015 |
Last Update Date | 20/06/2021 |