Provider Demographics
NPI:1518505692
Name:PALM BEACH GARDENS ORTHO LOCATION LLC
Entity Type:Organization
Organization Name:PALM BEACH GARDENS ORTHO LOCATION LLC
Other - Org Name:THE SMILE STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-658-4100
Mailing Address - Street 1:4362 NORTHLAKE BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6269
Mailing Address - Country:US
Mailing Address - Phone:561-658-4100
Mailing Address - Fax:866-333-2309
Practice Address - Street 1:4362 NORTHLAKE BLVD STE 114
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6269
Practice Address - Country:US
Practice Address - Phone:561-658-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON ORTHODONTIC SPECIALISTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-19
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105737100Medicaid