Provider Demographics
NPI:1740431980
Name:PALM BEACH ENDODONTICS, P.A.
Entity Type:Organization
Organization Name:PALM BEACH ENDODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-630-8900
Mailing Address - Street 1:11211 PROSPERITY FARMS RD
Mailing Address - Street 2:SUITE B107
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3446
Mailing Address - Country:US
Mailing Address - Phone:561-630-8900
Mailing Address - Fax:561-630-8909
Practice Address - Street 1:11211 PROSPERITY FARMS RD
Practice Address - Street 2:SUITE B107
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3446
Practice Address - Country:US
Practice Address - Phone:561-630-8900
Practice Address - Fax:561-630-8909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN138721223E0200X
FLDN165491223E0200X
FLDN138411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty