Provider Demographics
NPI:1801304977
Name:TRADITION DENTAL, P.A.
Entity type:Organization
Organization Name:TRADITION DENTAL, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARROUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-401-5006
Mailing Address - Street 1:1973 SW SAVAGE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2791
Mailing Address - Country:US
Mailing Address - Phone:772-207-1213
Mailing Address - Fax:772-877-2862
Practice Address - Street 1:1973 SW SAVAGE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2791
Practice Address - Country:US
Practice Address - Phone:772-207-1213
Practice Address - Fax:772-877-2862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty