Provider Demographics
NPI:1194992453
Name:ESTHETIC & IMPLANT DENTISTRY
Entity type:Organization
Organization Name:ESTHETIC & IMPLANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-683-4488
Mailing Address - Street 1:8136 OKEECHOBEE BLVD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411
Mailing Address - Country:US
Mailing Address - Phone:561-683-4488
Mailing Address - Fax:561-840-6491
Practice Address - Street 1:8136 OKEECHOBEE BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:561-683-4488
Practice Address - Fax:561-840-6491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9243261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073571000Medicaid