Provider Demographics
NPI:1942512868
Name:DENTAL TEAM OF WEST PALM BEACH
Entity type:Organization
Organization Name:DENTAL TEAM OF WEST PALM BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-999-9650
Mailing Address - Street 1:1497 FOREST HILL BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6052
Mailing Address - Country:US
Mailing Address - Phone:561-964-4699
Mailing Address - Fax:
Practice Address - Street 1:951 BROKEN SOUND PKWY
Practice Address - Street 2:185
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-3507
Practice Address - Country:US
Practice Address - Phone:561-999-9650
Practice Address - Fax:561-994-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty