Provider Demographics
NPI:1578807806
Name:JUPITER ORTHODONTICS INC
Entity Type:Organization
Organization Name:JUPITER ORTHODONTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:KERMIT
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-747-5766
Mailing Address - Street 1:24 N LOXAHATCHEE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3584
Mailing Address - Country:US
Mailing Address - Phone:561-747-5766
Mailing Address - Fax:561-744-2158
Practice Address - Street 1:24 N LOXAHATCHEE DR STE 4
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3584
Practice Address - Country:US
Practice Address - Phone:561-747-5766
Practice Address - Fax:561-744-2158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN72781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty