Provider Demographics
NPI:1013189075
Name:GLO AESTHETIC & LASER INSTITUTE LLC
Entity Type:Organization
Organization Name:GLO AESTHETIC & LASER INSTITUTE LLC
Other - Org Name:BOCA VIP DERMATOLOGY & LASER INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-704-4565
Mailing Address - Street 1:7945 PALACIO DEL MAR DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4149
Mailing Address - Country:US
Mailing Address - Phone:561-704-4565
Mailing Address - Fax:561-368-2264
Practice Address - Street 1:7100 W CAMINO REAL
Practice Address - Street 2:SUITE 206
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5510
Practice Address - Country:US
Practice Address - Phone:561-704-4565
Practice Address - Fax:561-368-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6841207NS0135X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty