Healthcare Provider Details

I. General information

NPI: 1184319477
Provider Name (Legal Business Name): PERIODONTICS & IMPLANT DENTISTRY OF BOCA FL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 S JOG RD STE 201
DELRAY BEACH FL
33446-2166
US

IV. Provider business mailing address

50 FORD WAY
RICHMOND HILL GA
31324-4438
US

V. Phone/Fax

Practice location:
  • Phone: 561-499-7400
  • Fax:
Mailing address:
  • Phone: 912-225-5054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MYLES MCALLISTER
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 727-403-4870