Provider Demographics
NPI:1174644686
Name:PALM BEACH MALL DENTAL GROUP
Entity Type:Organization
Organization Name:PALM BEACH MALL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-683-6247
Mailing Address - Street 1:1801 PALM BEACH LAKES BLVD STE 852
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2003
Mailing Address - Country:US
Mailing Address - Phone:561-683-6247
Mailing Address - Fax:561-683-6248
Practice Address - Street 1:1801 PALM BEACH LAKES BLVD STE 852
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2003
Practice Address - Country:US
Practice Address - Phone:561-683-6247
Practice Address - Fax:561-683-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL135911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherEIN