Provider Demographics
NPI:1164003786
Name:PEDIATRIC DENTAL CENTER OF PALMETTO BAY INC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CENTER OF PALMETTO BAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-368-6212
Mailing Address - Street 1:17037 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4362
Mailing Address - Country:US
Mailing Address - Phone:786-368-6212
Mailing Address - Fax:
Practice Address - Street 1:17037 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-4362
Practice Address - Country:US
Practice Address - Phone:786-368-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty