Healthcare Provider Details

I. General information

NPI: 1962769810
Provider Name (Legal Business Name): PEDIATRIC AND ADULT DENTISTRY OF THE PALM BEACHES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 BURNS ROAD SUITE 209
PALM BEACH GARDENS FL
33410-4308
US

IV. Provider business mailing address

3365 BURNS ROAD SUITE 209
PALM BEACH GARDENS FL
33410-4308
US

V. Phone/Fax

Practice location:
  • Phone: 561-775-1011
  • Fax: 561-775-8283
Mailing address:
  • Phone: 561-775-1011
  • Fax: 561-775-8283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16980
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN16968
License Number StateFL

VIII. Authorized Official

Name: YURI GOLDVASSER
Title or Position: PARTNER
Credential: D.D.S.
Phone: 561-775-1011