Provider Demographics
NPI:1861053480
Name:BOYNTON BEACH MALL DENTAL PA
Entity type:Organization
Organization Name:BOYNTON BEACH MALL DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-369-7199
Mailing Address - Street 1:801 N CONGRESS AVE STE 185D
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-3364
Mailing Address - Country:US
Mailing Address - Phone:561-369-7199
Mailing Address - Fax:
Practice Address - Street 1:801 N CONGRESS AVE STE 185D
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-3364
Practice Address - Country:US
Practice Address - Phone:561-369-7199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty