Healthcare Provider Details

I. General information

NPI: 1588905384
Provider Name (Legal Business Name): DOCTOR'S DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 COCONUT CREEK PKWY STE C
COCONUT CREEK FL
33066-1600
US

IV. Provider business mailing address

3850 COCONUT CREEK PKWY STE C
COCONUT CREEK FL
33066-1600
US

V. Phone/Fax

Practice location:
  • Phone: 954-917-7600
  • Fax:
Mailing address:
  • Phone: 954-917-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. RAUL LIZASO
Title or Position: OWNER
Credential: D.M.D
Phone: 954-917-7600