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General NPI Number Information
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NPI Number | 1184319477
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Entity Type | Organization
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Legal Business Name | PERIODONTICS & IMPLANT DENTISTRY OF BOCA FL PA
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Dates
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Enumeration Date | 04/11/2023
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Last Update Date | 04/11/2023
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Provider Practice Location Address
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Address Line | 15300 S JOG RD STE 201
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City | DELRAY BEACH
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State | FL
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Zip | 33446-2166
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Country | US
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Telephone | 561-499-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 50 FORD WAY
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City | RICHMOND HILL
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State | GA
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Zip | 31324-4438
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Country | US
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Telephone | 912-225-5054
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | MR. MYLES MCALLISTER
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Credential |
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Telephone | 727-403-4870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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