=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487872230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERON BAY DENTAL ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5960 CORAL RIDGE DR
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33076-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-255-5550
-----------------------------------------------------
Fax | 954-755-8276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5960 CORAL RIDGE DR
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33076-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-255-5550
-----------------------------------------------------
Fax | 954-755-8276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEITH MARLOWE FRIEFELD
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 954-255-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN11976
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------