Provider Demographics
NPI:1932276268
Name:PALM BAY DENTAL CENTER PA
Entity Type:Organization
Organization Name:PALM BAY DENTAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBHASH
Authorized Official - Middle Name:GANPAT
Authorized Official - Last Name:REGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-725-5512
Mailing Address - Street 1:1764 PALM BAY ROAD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2904
Mailing Address - Country:US
Mailing Address - Phone:321-725-5512
Mailing Address - Fax:321-725-5592
Practice Address - Street 1:1764 PALM BAY ROAD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2904
Practice Address - Country:US
Practice Address - Phone:321-725-5512
Practice Address - Fax:321-725-5592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL011148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty