Dew Anti-Aging and Med Spa LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

DEW ANTI-AGING AND MED SPA LLC

Practice address

7300 Sandlake Commons Blvd Ste 315
Orlando, FL 32819-8011

Phone

(407) 963-0125

NPI assigned

Jul 14, 2020

Last updated

Jul 14, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Gillian A Ellis, MD

Title

Owner/Provider

Phone

(407) 963-0125

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1594684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1594684800000",
    "number": "1073121232",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1624 KENNESAW DR",
            "city": "CLERMONT",
            "state": "FL",
            "postal_code": "347116871",
            "telephone_number": "407-963-0125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7300 SANDLAKE COMMONS BLVD STE 315",
            "city": "ORLANDO",
            "state": "FL",
            "postal_code": "328198011",
            "telephone_number": "407-963-0125"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEW ANTI-AGING AND MED SPA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-07-14",
        "last_updated": "2020-07-14",
        "certification_date": "2020-07-14",
        "status": "A",
        "authorized_official_last_name": "ELLIS",
        "authorized_official_first_name": "GILLIAN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER/PROVIDER",
        "authorized_official_telephone_number": "407-963-0125",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003163400",
            "state": "FL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "ORLANDO",
            "affiliation": "N",
            "endpointDescription": "PRACTICE OFFICE EMR",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "7300 Sandlake Commons Blvd Ste 315",
            "city": "Orlando",
            "state": "FL",
            "country_code": "US",
            "postal_code": "328198011",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Dina Grimailo Devine
• Ellen Devine
• Issachar Jude Devine, DO
• Bijita Devkota
• Brett Jordan Devoursney, DO
• Sameyeen Dewan, PHARM.D.
• Brianna Dewillis
• Daphne Lynne Dexter, RN
• Stephanie K Dexter, DMD
• Tasleene Dez, LPN

• Clinic/Center in Orlando, FL
• Providers in Orlando, FL by specialty
• Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.