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General NPI Number Information
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NPI Number | 1154694891
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Entity Type | Organization
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Legal Business Name | PEMBROKE DENTAL ASSOCIATES
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 02/10/2012
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Provider Practice Location Address
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Address Line | 12251 TAFT ST SUITE 404
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-1901
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Country | US
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Telephone | 954-432-7077
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Fax | 954-433-0748
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Provider Business Mailing Address
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Address Line | 12251 TAFT ST SUITE 404
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-1901
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Country | US
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Telephone | 954-432-7077
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Fax | 954-433-0748
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDGAR J PORRAS
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Credential | DDS
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Telephone | 954-432-7077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | DN11671
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License Number State | FL
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