=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417356973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESTYLE DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2014
-----------------------------------------------------
Last Update Date | 08/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 N FEDERAL HWY 101
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-750-6790
-----------------------------------------------------
Fax | 561-750-0535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 N FEDERAL HWY 101
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-750-6790
-----------------------------------------------------
Fax | 561-750-0535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. TATIANA SANTIAGO-HERZOG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 561-750-6790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN18993
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------