Provider Demographics
NPI:1154694891
Name:PEMBROKE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:PEMBROKE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:PORRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-432-7077
Mailing Address - Street 1:12251 TAFT ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1901
Mailing Address - Country:US
Mailing Address - Phone:954-432-7077
Mailing Address - Fax:954-433-0748
Practice Address - Street 1:12251 TAFT ST
Practice Address - Street 2:SUITE 404
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-1901
Practice Address - Country:US
Practice Address - Phone:954-432-7077
Practice Address - Fax:954-433-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN116711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001313400Medicaid