Provider Demographics
NPI:1013267145
Name:PREMIER DENTAL GROUP OF HALLANDALE
Entity type:Organization
Organization Name:PREMIER DENTAL GROUP OF HALLANDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-458-4584
Mailing Address - Street 1:1701 EAST HALLANDLE BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4621
Mailing Address - Country:US
Mailing Address - Phone:954-458-4584
Mailing Address - Fax:954-458-4078
Practice Address - Street 1:1701 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4621
Practice Address - Country:US
Practice Address - Phone:954-458-4584
Practice Address - Fax:954-458-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty