Provider Demographics
NPI:1598993321
Name:ILSE W. BERUBE, DMD, PA
Entity Type:Organization
Organization Name:ILSE W. BERUBE, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILSE
Authorized Official - Middle Name:WERNER
Authorized Official - Last Name:BERUBE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-723-0671
Mailing Address - Street 1:1937 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4205
Mailing Address - Country:US
Mailing Address - Phone:321-723-0671
Mailing Address - Fax:321-723-4454
Practice Address - Street 1:1937 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4205
Practice Address - Country:US
Practice Address - Phone:321-723-0671
Practice Address - Fax:321-723-4454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN142591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty