Healthcare Provider Details

I. General information

NPI: 1316144355
Provider Name (Legal Business Name): MAIN STREET ORTHODONTICS OF JUPITER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 TONEY PENNA DR STE 105
JUPITER FL
33458-5747
US

IV. Provider business mailing address

175 TONEY PENNA DR STE 105
JUPITER FL
33458-5747
US

V. Phone/Fax

Practice location:
  • Phone: 561-745-3118
  • Fax: 561-745-2440
Mailing address:
  • Phone: 561-745-3118
  • Fax: 561-745-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MELODY PARRISH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 305-274-2499