Healthcare Provider Details

I. General information

NPI: 1750951299
Provider Name (Legal Business Name): FL DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 W ATLANTIC AVE
DELRAY BEACH FL
33445-3838
US

IV. Provider business mailing address

4765 W ATLANTIC AVE
DELRAY BEACH FL
33445-3838
US

V. Phone/Fax

Practice location:
  • Phone: 561-859-5052
  • Fax: 954-374-6955
Mailing address:
  • Phone: 561-859-5052
  • Fax: 954-374-6955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MS. VICTORIA SAMUELSON
Title or Position: CEO
Credential:
Phone: 561-859-5052