Provider Demographics
NPI:1114073590
Name:BOULEVARD DENTAL LLC
Entity Type:Organization
Organization Name:BOULEVARD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-393-6024
Mailing Address - Street 1:8475 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4329
Mailing Address - Country:US
Mailing Address - Phone:727-393-6025
Mailing Address - Fax:727-397-5222
Practice Address - Street 1:8475 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4329
Practice Address - Country:US
Practice Address - Phone:727-393-6025
Practice Address - Fax:727-397-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6079122300000X
FLDN16886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty