Provider Demographics
NPI:1043360621
Name:PEDIATRIC DENTAL SERVICES
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KOERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-572-1500
Mailing Address - Street 1:6775 SUNSET STRIP
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313
Mailing Address - Country:US
Mailing Address - Phone:954-572-1500
Mailing Address - Fax:954-572-8501
Practice Address - Street 1:6775 SUNSET STRIP
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-2849
Practice Address - Country:US
Practice Address - Phone:954-572-1500
Practice Address - Fax:954-572-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN30781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty