1154694891 NPI number — PEMBROKE DENTAL ASSOCIATES

Table of content: (NPI 1154694891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154694891 NPI number — PEMBROKE DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEMBROKE DENTAL ASSOCIATES
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:
1154694891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12251 TAFT ST
Provider Second Line Business Mailing Address:
SUITE 404
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-432-7077
Provider Business Mailing Address Fax Number:
954-433-0748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12251 TAFT ST
Provider Second Line Business Practice Location Address:
SUITE 404
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-432-7077
Provider Business Practice Location Address Fax Number:
954-433-0748
Provider Enumeration Date:
02/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PORRAS
Authorized Official First Name:
EDGAR
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-432-7077

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  DN11671 , 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)

  • Identifier: 001313400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016773400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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