Provider Demographics
NPI:1154814143
Name:BOULEVARD DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BOULEVARD DENTAL ASSOCIATES, LLC
Other - Org Name:BOULEVARD DENTAL ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDIO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-538-9993
Mailing Address - Street 1:10794 PINES BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3920
Mailing Address - Country:US
Mailing Address - Phone:954-538-9993
Mailing Address - Fax:954-538-9994
Practice Address - Street 1:10794 PINES BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3920
Practice Address - Country:US
Practice Address - Phone:954-538-9993
Practice Address - Fax:954-538-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12326261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1427594258Other1427594258