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General NPI Number Information
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NPI Number | 1376766568
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Entity Type | Organization
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Legal Business Name | BROWARD MALL DENTAL, PA
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 12/03/2018
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Provider Practice Location Address
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Address Line | 8000 W BROWARD BLVD STE 834
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City | PLANTATION
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State | FL
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Zip | 33388-0023
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Country | US
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Telephone | 954-476-0802
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Fax |
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Provider Business Mailing Address
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Address Line | 8000 W BROWARD BLVD STE 834
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City | PLANTATION
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State | FL
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Zip | 33388-0023
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Country | US
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Telephone | 954-476-0802
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROSTISLAV KRASNOV
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Credential | DDS
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Telephone | 954-476-0802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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