Healthcare Provider Details

I. General information

NPI: 1033432281
Provider Name (Legal Business Name): MIZNER PARK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 PLAZA REAL SUITE 305
BOCA RATON FL
33432-3944
US

IV. Provider business mailing address

327 PLAZA REAL SUITE 305
BOCA RATON FL
33432-3944
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-3337
  • Fax:
Mailing address:
  • Phone: 561-391-3337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15874
License Number StateFL

VIII. Authorized Official

Name: MR. GEROGE SOROPOULOS
Title or Position: DENTIST
Credential: DDS, BSME
Phone: 561-395-1486