Provider Demographics
NPI:1255182515
Name:MY FAVORITE DENTAL BOUTIQUE LLC
Entity type:Organization
Organization Name:MY FAVORITE DENTAL BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISALES CANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-274-4744
Mailing Address - Street 1:1670 S US HIGHWAY 17 92
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-6516
Mailing Address - Country:US
Mailing Address - Phone:407-274-4744
Mailing Address - Fax:
Practice Address - Street 1:1670 S US HIGHWAY 17 92
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6516
Practice Address - Country:US
Practice Address - Phone:407-274-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty