=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861539934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY GANELES DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3020 N MILITARY TRL SUITE 200
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-912-9993
-----------------------------------------------------
Fax | 561-912-9883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3020 N MILITARY TRL SUITE 200
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-912-9993
-----------------------------------------------------
Fax | 561-912-9883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN0011979
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------