Provider Demographics
NPI:1902382815
Name:GENTLE TEETH OF PEMBROKE PINES
Entity Type:Organization
Organization Name:GENTLE TEETH OF PEMBROKE PINES
Other - Org Name:GENTLE TEETH OF PEMBROKE PINES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-437-7077
Mailing Address - Street 1:12251 TAFT ST STE 301
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1956
Mailing Address - Country:US
Mailing Address - Phone:954-437-7077
Mailing Address - Fax:844-260-5713
Practice Address - Street 1:12251 TAFT ST STE 301
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-1956
Practice Address - Country:US
Practice Address - Phone:954-437-7077
Practice Address - Fax:844-260-5713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17317261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental