=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558519488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORAL SPRINGS FAMILY DENTISTRY AT UNIVESITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2008
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2123 N UNIVERSITY DR
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33071-6134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-341-4766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10800 AVENIDA DEL RIO
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ILYA STEIN
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 954-341-4755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN14972
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------