Provider Demographics
NPI:1518441591
Name:TDC LAKEVIEW, LLC
Entity Type:Organization
Organization Name:TDC LAKEVIEW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-789-6611
Mailing Address - Street 1:8794 W BOYNTON BEACH BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4468
Mailing Address - Country:US
Mailing Address - Phone:561-789-6611
Mailing Address - Fax:
Practice Address - Street 1:1390 CORAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-5434
Practice Address - Country:US
Practice Address - Phone:954-752-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOMALTY DENTAL CARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty