Provider Demographics
NPI:1609012632
Name:WESTLAND MALL DENTAL, PA
Entity Type:Organization
Organization Name:WESTLAND MALL DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-828-7779
Mailing Address - Street 1:1665 W 49TH ST STE 1484
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2957
Mailing Address - Country:US
Mailing Address - Phone:305-828-7779
Mailing Address - Fax:305-828-7651
Practice Address - Street 1:1665 W 49TH ST STE 1484
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2957
Practice Address - Country:US
Practice Address - Phone:305-828-7779
Practice Address - Fax:305-828-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty