Provider Demographics
NPI:1043661796
Name:SHALOM SUNSET DENTAL CARE LLC
Entity Type:Organization
Organization Name:SHALOM SUNSET DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:MAIRENYSC
Authorized Official - Last Name:CASTELLO POLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-580-4367
Mailing Address - Street 1:6491 SUNSET STRIP
Mailing Address - Street 2:SUTIE #1
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313
Mailing Address - Country:US
Mailing Address - Phone:954-572-1801
Mailing Address - Fax:954-333-7561
Practice Address - Street 1:6491 SUNSET STRIP
Practice Address - Street 2:SUTIE #1
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-572-1801
Practice Address - Fax:954-333-7561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN209381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty