Provider Demographics
NPI:1770028243
Name:EAST DELRAY DENTAL, PLLC
Entity Type:Organization
Organization Name:EAST DELRAY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-276-2020
Mailing Address - Street 1:715 NE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-3822
Mailing Address - Country:US
Mailing Address - Phone:561-276-2020
Mailing Address - Fax:561-276-4713
Practice Address - Street 1:715 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-3822
Practice Address - Country:US
Practice Address - Phone:561-276-2020
Practice Address - Fax:561-276-4713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21073261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental