1295977015 NPI number — DENTAL ASSOCIATES OF BAL HARBOUR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295977015 NPI number — DENTAL ASSOCIATES OF BAL HARBOUR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL ASSOCIATES OF BAL HARBOUR
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:
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:
1295977015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10545 SW 74TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINECREST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33156-3882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-512-3187
Provider Business Mailing Address Fax Number:
305-740-9507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 95TH ST
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
SURFSIDE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33154-2807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-866-8290
Provider Business Practice Location Address Fax Number:
305-866-8298
Provider Enumeration Date:
03/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CORPAS
Authorized Official First Name:
ALFREDO
Authorized Official Middle Name:
DOMINGO
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
786-512-3178

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  DN0013451 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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