Provider Demographics
NPI:1003471459
Name:TDC PORT ST. LUCIE LLC
Entity Type:Organization
Organization Name:TDC PORT ST. LUCIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-789-6611
Mailing Address - Street 1:8794 W BOYNTON BEACH BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4468
Mailing Address - Country:US
Mailing Address - Phone:561-777-8980
Mailing Address - Fax:
Practice Address - Street 1:1161 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5332
Practice Address - Country:US
Practice Address - Phone:772-335-7766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty