=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972919132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLY SMILE ORTHODONTICS OF PEMBROKE PINES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 07/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N HIATUS RD SUITE 101
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-973-5725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 N HIATUS RD SUITE 101
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-973-5725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. ERNEST S ORPHANOS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 561-477-7171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------