Provider Demographics
NPI:1093737363
Name:PINE, PHILIP ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANDREW
Last Name:PINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S COMPASS DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2006
Mailing Address - Country:US
Mailing Address - Phone:954-782-1992
Mailing Address - Fax:954-782-0425
Practice Address - Street 1:1600 E ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6768
Practice Address - Country:US
Practice Address - Phone:954-782-1992
Practice Address - Fax:954-782-0425
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL101291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice