Provider Demographics
NPI:1912783150
Name:MY DENTIST OF PORT ST. LUCIE
Entity Type:Organization
Organization Name:MY DENTIST OF PORT ST. LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-633-9676
Mailing Address - Street 1:1455 SW GATLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953
Mailing Address - Country:US
Mailing Address - Phone:561-801-4233
Mailing Address - Fax:
Practice Address - Street 1:1455 SW GATLIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:561-801-4233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental