Provider Demographics
NPI:1457095630
Name:COSMETIC & IMPLANT DESIGNS GROUP PA
Entity Type:Organization
Organization Name:COSMETIC & IMPLANT DESIGNS GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERALTA LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-394-9364
Mailing Address - Street 1:4825 COCONUT CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33063-3944
Mailing Address - Country:US
Mailing Address - Phone:954-642-2203
Mailing Address - Fax:
Practice Address - Street 1:4825 COCONUT CREEK PKWY
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33063-3944
Practice Address - Country:US
Practice Address - Phone:954-642-2203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental