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General NPI Number Information
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NPI Number | 1003171703
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Entity Type | Organization
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Legal Business Name | FAMILY ORTHODONTICS
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 12797 FOREST HILL BLVD SUITE 6A
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City | WELLINGTON
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State | FL
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Zip | 33414-4763
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Country | US
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Telephone | 561-762-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 12797 FOREST HILL BLVD SUITE 6A
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City | WELLINGTON
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State | FL
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Zip | 33414-4763
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Country | US
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Telephone | 561-762-6200
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DANIEL BASS
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Credential | DMD, MS
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Telephone | 561-762-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN 18630
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License Number State | FL
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