Provider Demographics
NPI:1952687824
Name:SUPREME CARE DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SUPREME CARE DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMELSDORFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-296-5557
Mailing Address - Street 1:7138 S MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7812
Mailing Address - Country:US
Mailing Address - Phone:561-296-5557
Mailing Address - Fax:561-296-2557
Practice Address - Street 1:7138 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7812
Practice Address - Country:US
Practice Address - Phone:561-296-5557
Practice Address - Fax:561-296-2557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN144591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty