=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275385288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESMAN ORTHODONTICS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2024
-----------------------------------------------------
Last Update Date | 04/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 376 SW PRIMA VISTA BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-1984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-340-0023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 376 SW PRIMA VISTA BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-1984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. ALEXANDER ROBERT DESMAN
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 772-349-1092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------