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General NPI Number Information
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NPI Number | 1376937185
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Entity Type | Organization
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Legal Business Name | DENTAL BOOST PINES, LLC
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Dates
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Enumeration Date | 03/19/2015
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Last Update Date | 03/19/2015
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Provider Practice Location Address
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Address Line | 240 S FLAMINGO RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33027-1721
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Country | US
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Telephone | 954-437-0033
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Fax | 954-437-7796
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Provider Business Mailing Address
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Address Line | 240 S FLAMINGO RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33027-1721
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Country | US
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Telephone | 954-437-0033
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Fax | 954-437-7796
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | MRS. MARIANA GABALDON
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Credential | DENTIST
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Telephone | 305-822-4607
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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 | DN19159
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License Number State | FL
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