Provider Demographics
NPI:1790903508
Name:TREASURE COAST PERIODONTICS, PA
Entity Type:Organization
Organization Name:TREASURE COAST PERIODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:772-781-0744
Mailing Address - Street 1:900 SE OCEAN BLVD
Mailing Address - Street 2:BLDG.A, STE.102
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2471
Mailing Address - Country:US
Mailing Address - Phone:772-781-0744
Mailing Address - Fax:772-781-0748
Practice Address - Street 1:900 SE OCEAN BLVD
Practice Address - Street 2:BLDG.A, STE.102
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2471
Practice Address - Country:US
Practice Address - Phone:772-781-0744
Practice Address - Fax:772-781-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN122521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty