=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134915119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BV PALMETTO BAY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2025
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9000 SW 152ND ST STE 101
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-1941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-984-8235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8331 GUNN HWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33626-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-398-5423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANDREW M VALLO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-398-5423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------