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General NPI Number Information
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NPI Number | 1730694191
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTAL WELLNESS CENTER
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Dates
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Enumeration Date | 12/07/2017
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Last Update Date | 12/07/2017
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Provider Practice Location Address
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Address Line | 104 SE 1ST ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33301-1924
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Country | US
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Telephone | 954-525-5662
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Fax | 954-525-5251
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Provider Business Mailing Address
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Address Line | 104 SE 1ST ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33301-1924
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Country | US
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Telephone | 954-525-5662
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BORIS LIPOVETSKIY
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Credential |
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Telephone | 954-525-5662
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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 | DN21039
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License Number State | FL
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