Provider Demographics
NPI:1417356973
Name:LIFESTYLE DENTAL GROUP
Entity Type:Organization
Organization Name:LIFESTYLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO-HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-750-6790
Mailing Address - Street 1:3401 N FEDERAL HWY
Mailing Address - Street 2:101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6046
Mailing Address - Country:US
Mailing Address - Phone:561-750-6790
Mailing Address - Fax:561-750-0535
Practice Address - Street 1:3401 N FEDERAL HWY
Practice Address - Street 2:101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6046
Practice Address - Country:US
Practice Address - Phone:561-750-6790
Practice Address - Fax:561-750-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty