1609352905 NPI number — SHAPIRO FAMILY DENTISTRY OF FORT PIERCE PA

Table of content: (NPI 1609352905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609352905 NPI number — SHAPIRO FAMILY DENTISTRY OF FORT PIERCE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAPIRO FAMILY DENTISTRY OF FORT PIERCE 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:
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:
1609352905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2247 PALM BEACH LAKES BLVD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33409-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-254-2868
Provider Business Mailing Address Fax Number:
561-328-6217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CORAL SQUARE SHOPPES 3006 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
SUITE D2/D3
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-242-0053
Provider Business Practice Location Address Fax Number:
772-242-0081
Provider Enumeration Date:
07/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHAPIRO
Authorized Official First Name:
DARI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-254-2868

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010511900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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