Healthcare Provider Details

I. General information

NPI: 1194920942
Provider Name (Legal Business Name): SETH HOWARD RIEBACK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MILITARY TRL SUITE 330
BOCA RATON FL
33431-6312
US

IV. Provider business mailing address

2600 N MILITARY TRL SUITE 330
BOCA RATON FL
33431-6312
US

V. Phone/Fax

Practice location:
  • Phone: 561-241-9440
  • Fax: 561-241-4922
Mailing address:
  • Phone: 561-241-9440
  • Fax: 561-241-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: