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General NPI Number Information
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NPI Number | 1962010652
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Entity Type | Organization
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Legal Business Name | CL DDS 2 PA
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Dates
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Enumeration Date | 07/19/2020
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Last Update Date | 07/19/2020
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Provider Practice Location Address
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Address Line | 9156 WILES RD
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City | CORAL SPRINGS
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State | FL
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Zip | 33067-1999
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Country | US
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Telephone | 954-255-2787
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Fax |
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Provider Business Mailing Address
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Address Line | 3320 SW 58TH ST
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City | FT LAUDERDALE
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State | FL
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Zip | 33312-6365
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Country | US
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Telephone | 443-235-2403
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CRAIG LUSTMAN
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Credential | DDS
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Telephone | 954-255-2787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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