Provider Demographics
NPI:1043528680
Name:POINCIANA DENTAL, LLC
Entity Type:Organization
Organization Name:POINCIANA DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOESCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-846-4775
Mailing Address - Street 1:873 CYPRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:POINCIANA
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3408
Mailing Address - Country:US
Mailing Address - Phone:407-846-4775
Mailing Address - Fax:
Practice Address - Street 1:873 CYPRESS PKWY
Practice Address - Street 2:
Practice Address - City:POINCIANA
Practice Address - State:FL
Practice Address - Zip Code:34759-3408
Practice Address - Country:US
Practice Address - Phone:407-846-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15940305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service