Provider Demographics
NPI:1932483864
Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF BOCA RATON, P.A.
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF BOCA RATON, P.A.
Other - Org Name:MAIN STREET CHILDREN'S DENTISTRY OF BOCA RATON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4461
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:
Practice Address - Street 1:595 S FEDERAL HWY STE 130
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-6096
Practice Address - Country:US
Practice Address - Phone:561-826-7955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty