Provider Demographics
NPI:1497845440
Name:PALM BEACH MALL DENTAL GROUP,PL
Entity Type:Organization
Organization Name:PALM BEACH MALL DENTAL GROUP,PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LORETTA
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-683-6247
Mailing Address - Street 1:1801 PALM BEACH LAKES BLVD
Mailing Address - Street 2:#852
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2020
Mailing Address - Country:US
Mailing Address - Phone:561-683-6247
Mailing Address - Fax:561-683-6248
Practice Address - Street 1:1801 PALM BEACH LAKES BLVD
Practice Address - Street 2:#852
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2020
Practice Address - Country:US
Practice Address - Phone:561-683-6247
Practice Address - Fax:561-683-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00135911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty