1962769810 NPI number — PEDIATRIC AND ADULT DENTISTRY OF THE PALM BEACHES PLLC

Table of content: (NPI 1962769810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962769810 NPI number — PEDIATRIC AND ADULT DENTISTRY OF THE PALM BEACHES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC AND ADULT DENTISTRY OF THE PALM BEACHES PLLC
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:
1962769810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3365 BURNS ROAD
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-775-1011
Provider Business Mailing Address Fax Number:
561-775-8283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3365 BURNS ROAD
Provider Second Line Business Practice Location Address:
SUITE 209
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:
33410-4308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-775-1011
Provider Business Practice Location Address Fax Number:
561-775-8283
Provider Enumeration Date:
04/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDVASSER
Authorized Official First Name:
YURI
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
561-775-1011

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN16980 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: DN16968 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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