Healthcare Provider Details

I. General information

NPI: 1962154849
Provider Name (Legal Business Name): NICHOLAS THEODORE FUNYAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2022
Last Update Date: 02/02/2025
Certification Date: 02/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 MILITARY TRL
JUPITER FL
33458-4819
US

IV. Provider business mailing address

5261 BECKMAN TER
PALM BEACH GARDENS FL
33418-6235
US

V. Phone/Fax

Practice location:
  • Phone: 561-748-5099
  • Fax:
Mailing address:
  • Phone: 406-697-5792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN28296
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: