Provider Demographics
NPI:1922419597
Name:BRANDON MALL DENTAL P.A.
Entity Type:Organization
Organization Name:BRANDON MALL DENTAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:954-846-7171
Mailing Address - Street 1:675 BRANDON TOWN CENTER MALL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4770
Mailing Address - Country:US
Mailing Address - Phone:954-846-7171
Mailing Address - Fax:
Practice Address - Street 1:675 BRANDON TOWN CENTER MALL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4770
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty