Provider Demographics
NPI:1740603380
Name:BANYAN DENTAL SVC PSL, LLC
Entity Type:Organization
Organization Name:BANYAN DENTAL SVC PSL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JADE
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-344-3300
Mailing Address - Street 1:1707 NW ST. LUCIE W. BLVD
Mailing Address - Street 2:#126
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:772-344-3300
Mailing Address - Fax:772-344-3301
Practice Address - Street 1:1707 NW ST. LUCIE W. BLVD
Practice Address - Street 2:#126
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986
Practice Address - Country:US
Practice Address - Phone:772-344-3300
Practice Address - Fax:772-344-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty