Provider Demographics
NPI:1003285339
Name:ADVANCED DENTISTRY SOUTH FLORIDA SEPCIALISTS LLC
Entity Type:Organization
Organization Name:ADVANCED DENTISTRY SOUTH FLORIDA SEPCIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER STALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-495-2099
Mailing Address - Street 1:15340 JOG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-2170
Mailing Address - Country:US
Mailing Address - Phone:561-495-2099
Mailing Address - Fax:
Practice Address - Street 1:15340 JOG RD STE 100
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-2170
Practice Address - Country:US
Practice Address - Phone:561-495-2099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD J STALLER DDS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty