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General NPI Number Information
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NPI Number | 1649060021
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Entity Type | Organization
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Legal Business Name | VALLO FT MYERS PLLC THE DENTAL BOUTIQUE FORT MYERS
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Dates
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Enumeration Date | 05/08/2025
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Last Update Date | 05/08/2025
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Provider Practice Location Address
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Address Line | 5100 S CLEVELAND AVE FL 33907
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City | FORT MYERS
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State | FL
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Zip | 33907-2189
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Country | US
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Telephone | 239-327-0862
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Fax |
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Provider Business Mailing Address
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Address Line | 5100 S CLEVELAND AVE FL 33907
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City | FORT MYERS
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State | FL
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Zip | 33907-2189
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Country | US
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Telephone | 239-327-0862
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Fax |
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Authorized Official
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Title or Position | OPERATIONS OFFICER
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Name | MANUEL COBOS
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Credential |
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Telephone | 773-398-5423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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