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General NPI Number Information
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NPI Number | 1861053480
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Entity Type | Organization
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Legal Business Name | BOYNTON BEACH MALL DENTAL PA
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Dates
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Enumeration Date | 06/25/2019
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 801 N CONGRESS AVE STE 185D
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City | BOYNTON BEACH
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State | FL
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Zip | 33426-3364
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Country | US
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Telephone | 561-369-7199
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Fax |
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Provider Business Mailing Address
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Address Line | 801 N CONGRESS AVE STE 185D
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City | BOYNTON BEACH
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State | FL
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Zip | 33426-3364
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Country | US
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Telephone | 561-369-7199
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROSTISLAV KRASNOV
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Credential |
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Telephone | 561-369-7199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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