Provider Demographics
NPI:1467839522
Name:PETTISSHEPARDDENTASTIC LLC
Entity Type:Organization
Organization Name:PETTISSHEPARDDENTASTIC LLC
Other - Org Name:DENTASTIC DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:954-781-4670
Mailing Address - Street 1:2747 E ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4941
Mailing Address - Country:US
Mailing Address - Phone:954-781-4670
Mailing Address - Fax:
Practice Address - Street 1:2747 E ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-4941
Practice Address - Country:US
Practice Address - Phone:954-781-4670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7571122300000X
FLDN19680122300000X
FLDN19879122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty