Provider Demographics
NPI:1235243189
Name:PELTON, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:PELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12558 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1713
Mailing Address - Country:US
Mailing Address - Phone:954-639-6998
Mailing Address - Fax:754-206-4282
Practice Address - Street 1:12558 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1713
Practice Address - Country:US
Practice Address - Phone:954-639-6998
Practice Address - Fax:754-206-4282
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN58381223G0001X
FLDN155851223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1730203100OtherDMD