=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912783150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY DENTIST OF PORT ST. LUCIE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2023
-----------------------------------------------------
Last Update Date | 09/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 SW GATLIN BLVD
-----------------------------------------------------
City | PORT ST. LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-801-4233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1455 SW GATLIN BLVD
-----------------------------------------------------
City | PORT ST. LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-801-4233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JORDAN TOMALTY
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 561-633-9676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------