Provider Demographics
NPI:1659936656
Name:PEMBROKE DENTAL & SPA PL
Entity Type:Organization
Organization Name:PEMBROKE DENTAL & SPA PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-488-3507
Mailing Address - Street 1:21239 NE 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15671 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1204
Practice Address - Country:US
Practice Address - Phone:954-419-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental