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General NPI Number Information
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NPI Number | 1972930774
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Entity Type | Organization
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Legal Business Name | POMPANO BEACH PERIODONTICS PLLC
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Dates
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Enumeration Date | 10/11/2013
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Last Update Date | 10/11/2013
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Provider Practice Location Address
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Address Line | 2231 NE 25TH AVE SUITE 4
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City | POMPANO BEACH
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State | FL
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Zip | 33062-1148
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Country | US
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Telephone | 954-782-7911
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Fax | 954-782-7925
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Provider Business Mailing Address
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Address Line | 2231 NE 25TH AVE SUITE 4
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City | POMPANO BEACH
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State | FL
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Zip | 33062-1148
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Country | US
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Telephone | 954-782-7911
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Fax | 954-782-7925
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Authorized Official
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Title or Position | MANAGINGMEMBER
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Name | DR. JASON A WITONSKY
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Credential | DMD
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Telephone | 954-782-7911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN18938
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License Number State | FL
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