=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851771018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEDA DENTAL OF PINECREST, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2015
-----------------------------------------------------
Last Update Date | 06/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9507 S. DIXIE HIGHWAY
-----------------------------------------------------
City | PINECREST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-859-7949
-----------------------------------------------------
Fax | 305-859-9585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10075 JOG ROAD SUITE 108
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-738-9007
-----------------------------------------------------
Fax | 561-738-9963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. KENNETH DAVID RUBINSTEIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 561-738-9007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN14485
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------