Provider Demographics
NPI:1871824581
Name:ORAL AND MAXILLOFACIAL SURGERY OF THE PALM BEACHES, LLC
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY OF THE PALM BEACHES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLF
Authorized Official - Middle Name:B
Authorized Official - Last Name:WOLFROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-242-9990
Mailing Address - Street 1:1920 PALM BEACH LAKES BLVD
Mailing Address - Street 2:105
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3512
Mailing Address - Country:US
Mailing Address - Phone:561-242-9990
Mailing Address - Fax:561-242-9994
Practice Address - Street 1:1920 PALM BEACH LAKES BLVD
Practice Address - Street 2:105
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3512
Practice Address - Country:US
Practice Address - Phone:561-242-9990
Practice Address - Fax:561-242-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN86381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU09788Medicare UPIN