Healthcare Provider Details

I. General information

NPI: 1881063477
Provider Name (Legal Business Name): ETTIE HORESH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12801 W SUNRISE BLVD SUITE F222
SUNRISE FL
33323-4020
US

IV. Provider business mailing address

12801 W SUNRISE BLVD SUITE F222
SUNRISE FL
33323-4020
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax:
Mailing address:
  • Phone: 954-846-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21340
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: