Provider Demographics
NPI:1902027683
Name:PEDIATRIC AND ORTHODONTIC DENTAL CENTERS OF BROWARD
Entity Type:Organization
Organization Name:PEDIATRIC AND ORTHODONTIC DENTAL CENTERS OF BROWARD
Other - Org Name:PEDIATRIC DENTAL CENTERS OF BROWARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-341-0002
Mailing Address - Street 1:8351 W ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-7454
Mailing Address - Country:US
Mailing Address - Phone:954-341-0002
Mailing Address - Fax:
Practice Address - Street 1:8351 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-7454
Practice Address - Country:US
Practice Address - Phone:954-341-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN172841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076110900Medicaid
FL076240700Medicaid
FL076721200Medicaid