1275000879 NPI number — DENTISTS OF PALM BEACH GARDENS, PA

Table of content: (NPI 1275000879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275000879 NPI number — DENTISTS OF PALM BEACH GARDENS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTISTS OF PALM BEACH GARDENS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275000879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 920050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75392-0050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
303-952-0982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5380 DONALD ROSS, RD.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-323-7117
Provider Business Practice Location Address Fax Number:
561-693-4484
Provider Enumeration Date:
11/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDERS
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/GENERAL DENTIST
Authorized Official Telephone Number:
561-323-7117

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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