Provider Demographics
NPI:1154348233
Name:SAVASTANO, JR., NICHOLAS JOHN JR (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:SAVASTANO, JR.
Suffix:JR
Gender:M
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:NICK
Other - Middle Name:J
Other - Last Name:SAVASTANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, MS
Mailing Address - Street 1:4362 NORTHLAKE BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6269
Mailing Address - Country:US
Mailing Address - Phone:561-658-4100
Mailing Address - Fax:866-333-2309
Practice Address - Street 1:4362 NORTHLAKE BLVD STE 114
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6269
Practice Address - Country:US
Practice Address - Phone:561-658-4100
Practice Address - Fax:866-333-2309
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD 8789 DS1223X0400X
FLDN154871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105737100Medicaid
SCZX8789Medicaid
FL9006776OtherDELTA DENTAL PROVIDER #
FL86838OtherBCBS PROVIDER #
FL1953103OtherUNITED CONCORDIA PROVIDER
FLBS9026279OtherDEA #