Healthcare Provider Details

I. General information

NPI: 1275906232
Provider Name (Legal Business Name): BOULEVARD CENTER FOR ADVANCED DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5366
US

IV. Provider business mailing address

1343 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5366
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN13975
License Number StateFL

VIII. Authorized Official

Name: DR. JEROME VITALE
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 772-337-1111