Provider Demographics
NPI:1467485599
Name:BROUMAND, VISHTASB (DMD, MD)
Entity Type:Individual
Prefix:
First Name:VISHTASB
Middle Name:
Last Name:BROUMAND
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 RCA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3335
Mailing Address - Country:US
Mailing Address - Phone:561-622-9065
Mailing Address - Fax:
Practice Address - Street 1:9380 SW 150TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7947
Practice Address - Country:US
Practice Address - Phone:305-256-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN145331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery