=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285030148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL J. HOLCROFT, DMD.PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2014
-----------------------------------------------------
Last Update Date | 11/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2560 RCA BLVD SUITE 101
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-622-5600
-----------------------------------------------------
Fax | 561-622-5601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2560 RCA BLVD SUITE 101
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-622-5600
-----------------------------------------------------
Fax | 561-622-5601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. SAMUEL J. HOLCROFT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 561-622-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 15900
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------