Provider Demographics
NPI:1619372760
Name:AEGEAN DENTAL OF PORT ST LUCIE, LLC
Entity Type:Organization
Organization Name:AEGEAN DENTAL OF PORT ST LUCIE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, BSME
Authorized Official - Phone:561-395-1486
Mailing Address - Street 1:2151 NW 2ND AVE
Mailing Address - Street 2:101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6771
Mailing Address - Country:US
Mailing Address - Phone:561-395-1486
Mailing Address - Fax:
Practice Address - Street 1:308 NW BETHANY DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3578
Practice Address - Country:US
Practice Address - Phone:772-344-4356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty