Provider Demographics
NPI:1114006434
Name:JUPITER PROSTHODONTICS
Entity Type:Organization
Organization Name:JUPITER PROSTHODONTICS
Other - Org Name:JUPITER INSTITUTE FOR PROSTHODONTICS & IMPLANT DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:561-745-5550
Mailing Address - Street 1:200 CENTRAL BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-745-5550
Mailing Address - Fax:561-745-8442
Practice Address - Street 1:200 CENTRAL BLVD
Practice Address - Street 2:STE A
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-745-5550
Practice Address - Fax:561-745-8442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN95511223P0700X
FLDN165121223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty