Provider Demographics
NPI:1780067637
Name:LAURIE B. GITTESS
Entity type:Organization
Organization Name:LAURIE B. GITTESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-389-2345
Mailing Address - Street 1:1625 N COMMERCE PKWY
Mailing Address - Street 2:STE 317
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3216
Mailing Address - Country:US
Mailing Address - Phone:954-389-2345
Mailing Address - Fax:
Practice Address - Street 1:1625 N COMMERCE PKWY
Practice Address - Street 2:STE 317
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3216
Practice Address - Country:US
Practice Address - Phone:954-389-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19566122300000X
OH134741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007987200Medicaid
FL010596200Medicaid