Provider Demographics
NPI:1376937185
Name:DENTAL BOOST PINES, LLC
Entity Type:Organization
Organization Name:DENTAL BOOST PINES, LLC
Other - Org Name:DENTAL BOOST, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABALDON
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:305-822-4607
Mailing Address - Street 1:240 S FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1721
Mailing Address - Country:US
Mailing Address - Phone:954-437-0033
Mailing Address - Fax:954-437-7796
Practice Address - Street 1:240 S FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1721
Practice Address - Country:US
Practice Address - Phone:954-437-0033
Practice Address - Fax:954-437-7796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL BOOST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19159261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental