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General NPI Number Information
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NPI Number | 1396377172
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Entity Type | Organization
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Legal Business Name | SOUTH PEARL DENTAL, INC
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Dates
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Enumeration Date | 02/10/2020
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Last Update Date | 02/10/2020
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Provider Practice Location Address
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Address Line | 8903 GLADES RD STE A7
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City | BOCA RATON
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State | FL
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Zip | 33434-4023
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Country | US
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Telephone | 352-727-8547
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Fax |
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Provider Business Mailing Address
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Address Line | 8665 VIA ANCHO RD
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City | BOCA RATON
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State | FL
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Zip | 33433-2227
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. MARIANGEL FERNANDEZ-MARTINEZ
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Credential | DMD
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Telephone | 352-727-8547
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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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