Healthcare Provider Details

I. General information

NPI: 1992809511
Provider Name (Legal Business Name): MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF PLANTATION, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 S UNIVERSITY DR
PLANTATION FL
33324-3344
US

IV. Provider business mailing address

318 S UNIVERSITY DR
PLANTATION FL
33324-3344
US

V. Phone/Fax

Practice location:
  • Phone: 954-474-8849
  • Fax:
Mailing address:
  • Phone: 954-474-8849
  • Fax:

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