Healthcare Provider Details

I. General information

NPI: 1285869933
Provider Name (Legal Business Name): BOCA RATON CENTER FOR ORAL FACIAL & IMPLANT SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 GLADES RD SUITE 309
BOCA RATON FL
33431-7202
US

IV. Provider business mailing address

2499 GLADES RD SUITE 309
BOCA RATON FL
33431-7202
US

V. Phone/Fax

Practice location:
  • Phone: 561-826-2002
  • Fax: 561-826-2003
Mailing address:
  • Phone: 561-826-2002
  • Fax: 561-826-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN17306
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16134
License Number StateFL

VIII. Authorized Official

Name: MS. CARLA PICCONE
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 561-826-2002