Healthcare Provider Details

I. General information

NPI: 1982117784
Provider Name (Legal Business Name): BERYL SUE KASSOFF-CORREIA CRDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CLINT MOORE RD STE 138
BOCA RATON FL
33487-2801
US

IV. Provider business mailing address

920 CLINT MOORE RD STE 138
BOCA RATON FL
33487-2801
US

V. Phone/Fax

Practice location:
  • Phone: 561-804-5600
  • Fax:
Mailing address:
  • Phone: 561-804-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH22926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: