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General NPI Number Information
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NPI Number | 1013189075
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Entity Type | Organization
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Legal Business Name | GLO AESTHETIC & LASER INSTITUTE LLC
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Dates
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Enumeration Date | 03/31/2008
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Last Update Date | 12/03/2008
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Provider Practice Location Address
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Address Line | 7100 W CAMINO REAL SUITE 206
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City | BOCA RATON
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State | FL
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Zip | 33433-5510
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Country | US
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Telephone | 561-704-4565
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Fax | 561-368-2264
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Provider Business Mailing Address
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Address Line | 7945 PALACIO DEL MAR DR
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City | BOCA RATON
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State | FL
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Zip | 33433-4149
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Country | US
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Telephone | 561-704-4565
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Fax | 561-368-2264
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JACK ALAN DANTON
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Credential | DO
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Telephone | 561-704-4565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS6841
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | OS6841
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License Number State | FL
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