1760687149 NPI number — MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WELLINGTON, PA

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 1760687149 NPI number — MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WELLINGTON, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WELLINGTON, 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:
1760687149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13195 SW 134 ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-274-2499
Provider Business Mailing Address Fax Number:
561-422-2945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11903 SOUTHERN BLVD.
Provider Second Line Business Practice Location Address:
SUITE #102
Provider Business Practice Location Address City Name:
ROYAL PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-422-2940
Provider Business Practice Location Address Fax Number:
561-422-2945
Provider Enumeration Date:
06/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER RELATIONS
Authorized Official Telephone Number:
305-274-2499

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , 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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