Provider Demographics
NPI:1841492634
Name:PALM BEACH MALL DENTAL, PA
Entity type:Organization
Organization Name:PALM BEACH MALL DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-683-6247
Mailing Address - Street 1:1801 PALM BEACH LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2020
Mailing Address - Country:US
Mailing Address - Phone:561-683-6247
Mailing Address - Fax:561-683-6248
Practice Address - Street 1:1801 PALM BEACH LAKES BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2020
Practice Address - Country:US
Practice Address - Phone:561-683-6247
Practice Address - Fax:561-683-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID NUMBER