Provider Demographics
NPI:1154400497
Name:SOUTHEASTERN DENTAL ASSOCIATES I
Entity type:Organization
Organization Name:SOUTHEASTERN DENTAL ASSOCIATES I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUBINSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-738-9007
Mailing Address - Street 1:200 KNUTH ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436
Mailing Address - Country:US
Mailing Address - Phone:561-738-9007
Mailing Address - Fax:561-738-9963
Practice Address - Street 1:200 KNUTH ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436
Practice Address - Country:US
Practice Address - Phone:561-738-9007
Practice Address - Fax:561-738-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN157611223P0300X
FLDN144851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty