=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235702887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONITA PALM DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2021
-----------------------------------------------------
Last Update Date | 07/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9776 BONITA BEACH RD SE STE 202A
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-221-7079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9776 BONITA BEACH RD SE STE 202A
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-221-7079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. MAXIMUS ZAND
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 239-810-0821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------