Provider Demographics
NPI:1568081909
Name:HALLANDALE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:HALLANDALE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-718-3384
Mailing Address - Street 1:200 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-5525
Mailing Address - Country:US
Mailing Address - Phone:954-718-3384
Mailing Address - Fax:561-431-2468
Practice Address - Street 1:200 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-5525
Practice Address - Country:US
Practice Address - Phone:954-718-3384
Practice Address - Fax:561-431-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1972807204OtherNPI TYPE 1