Provider Demographics
NPI:1053786038
Name:TDC CANYON LLC
Entity type:Organization
Organization Name:TDC CANYON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-777-8980
Mailing Address - Street 1:8794 W BOYNTON BEACH BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4468
Mailing Address - Country:US
Mailing Address - Phone:561-777-8980
Mailing Address - Fax:561-777-8608
Practice Address - Street 1:8794 W BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4468
Practice Address - Country:US
Practice Address - Phone:561-777-8980
Practice Address - Fax:561-777-8608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental