Provider Demographics
NPI:1780266734
Name:INDIAN TRACE DENTAL ASSOCIATES,P.A.
Entity type:Organization
Organization Name:INDIAN TRACE DENTAL ASSOCIATES,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-217-9200
Mailing Address - Street 1:46 INDIAN TRCE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-4551
Mailing Address - Country:US
Mailing Address - Phone:954-217-9200
Mailing Address - Fax:
Practice Address - Street 1:46 INDIAN TRCE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-4551
Practice Address - Country:US
Practice Address - Phone:954-217-9200
Practice Address - Fax:954-217-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093899171OtherNPI