Healthcare Provider Details

I. General information

NPI: 1003171703
Provider Name (Legal Business Name): FAMILY ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12797 FOREST HILL BLVD SUITE 6A
WELLINGTON FL
33414-4763
US

IV. Provider business mailing address

12797 FOREST HILL BLVD SUITE 6A
WELLINGTON FL
33414-4763
US

V. Phone/Fax

Practice location:
  • Phone: 561-762-6200
  • Fax:
Mailing address:
  • Phone: 561-762-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18630
License Number StateFL

VIII. Authorized Official

Name: DANIEL BASS
Title or Position: ORTHODONTIST
Credential: DMD, MS
Phone: 561-762-6200