Healthcare Provider Details

I. General information

NPI: 1013189075
Provider Name (Legal Business Name): GLO AESTHETIC & LASER INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 W CAMINO REAL SUITE 206
BOCA RATON FL
33433-5510
US

IV. Provider business mailing address

7945 PALACIO DEL MAR DR
BOCA RATON FL
33433-4149
US

V. Phone/Fax

Practice location:
  • Phone: 561-704-4565
  • Fax: 561-368-2264
Mailing address:
  • Phone: 561-704-4565
  • Fax: 561-368-2264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberOS6841
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS6841
License Number StateFL

VIII. Authorized Official

Name: DR. JACK ALAN DANTON
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 561-704-4565