Healthcare Provider Details

I. General information

NPI: 1679620942
Provider Name (Legal Business Name): PEMBROKE PINES DENTAL HEALTH CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 NW 125TH AVE #170
PEMBROKE PINES FL
33028-2596
US

IV. Provider business mailing address

1851 NW 125 AVE #170
PEMBROKE PINES FL
33028
US

V. Phone/Fax

Practice location:
  • Phone: 954-437-2040
  • Fax: 954-437-4573
Mailing address:
  • Phone: 954-437-2040
  • Fax: 954-437-4573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN 16213
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN VICTOR SOOTIN
Title or Position: OWNER
Credential: D.D.S.
Phone: 954-437-2040