Provider Demographics
NPI:1063552727
Name:DENTAL STORE INC
Entity type:Organization
Organization Name:DENTAL STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-395-1486
Mailing Address - Street 1:2151 NW 2ND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431
Mailing Address - Country:US
Mailing Address - Phone:561-395-1486
Mailing Address - Fax:561-395-1525
Practice Address - Street 1:2151 NW 2ND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431
Practice Address - Country:US
Practice Address - Phone:561-395-1486
Practice Address - Fax:561-395-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN60991223E0200X
FLDN80301223G0001X
FLDN178011223P0300X
FLDN169731223P0300X
FLDN158741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty