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General NPI Number Information
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NPI Number | 1568813491
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY COSMETIC DENTISTRY
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Dates
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Enumeration Date | 06/22/2016
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Last Update Date | 06/22/2016
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Provider Practice Location Address
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Address Line | 5359 LYONS RD
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City | COCONUT CREEK
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State | FL
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Zip | 33073-2825
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Country | US
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Telephone | 954-570-8870
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Fax | 954-571-6736
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Provider Business Mailing Address
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Address Line | 5359 LYONS RD
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City | COCONUT CREEK
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State | FL
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Zip | 33073-2825
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Country | US
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Telephone | 954-570-8870
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Fax | 954-571-6736
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Authorized Official
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Title or Position | OWNER
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Name | DR. MANON BOURQUE HUTCHISON
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Credential |
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Telephone | 954-570-8870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN5044
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | DN19185
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN0011990
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH15026
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License Number State | FL
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN13436
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License Number State | FL
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