MEDICARE: PALM BEACH MALL DENTAL, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1841492634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM BEACH MALL DENTAL, PA

Provider Business Mailing Address
First Line	:	1801 PALM BEACH LAKES BLVD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-2020
Country	:	US
Telephone Number	:	561-683-6247
Fax Number	:	561-683-6248

Provider Business Practice Location Address
First Line	:	1801 PALM BEACH LAKES BLVD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-2020
Country	:	US
Telephone Number	:	561-683-6247
Fax Number	:	561-683-6248

Authorized Official
Title or Position	:	OWNER
Name	:	ROSTISLAV KRASNOV
Credential	:	DDS
Telephone Number	:	561-683-6247

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	12/03/2018

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