=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841689791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERAVOLO & CERAVOLO, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2015
-----------------------------------------------------
Last Update Date | 01/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3365 BURNS RD SUITE 201
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-622-6580
-----------------------------------------------------
Fax | 561-622-6665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3365 BURNS RD SUITE 201
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-622-6580
-----------------------------------------------------
Fax | 561-622-6665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH CERAVOLO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 561-622-6580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN10720
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------