Provider Demographics
NPI:1831236223
Name:PALM BEACH PERIODONTICS, P.C.
Entity type:Organization
Organization Name:PALM BEACH PERIODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GORNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:561-967-0476
Mailing Address - Street 1:1840 FOREST HILL BLVD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6063
Mailing Address - Country:US
Mailing Address - Phone:561-967-0476
Mailing Address - Fax:561-967-9138
Practice Address - Street 1:1840 FOREST HILL BLVD
Practice Address - Street 2:SUITE #202
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-6063
Practice Address - Country:US
Practice Address - Phone:561-967-0476
Practice Address - Fax:561-967-9138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN154131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty