Healthcare Provider Details

I. General information

NPI: 1881467603
Provider Name (Legal Business Name): PINES PALM DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9964 PINES BLVD
PEMBROKE PINES FL
33024-6139
US

IV. Provider business mailing address

9964 PINES BLVD
PEMBROKE PINES FL
33024-6139
US

V. Phone/Fax

Practice location:
  • Phone: 954-432-6222
  • Fax:
Mailing address:
  • Phone: 954-432-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: HILDA POVEDA
Title or Position: OFFICE MANAGER
Credential:
Phone: 954-432-6222