Provider Demographics
NPI:1306088133
Name:SAWGRASS MILLS MALL DENTAL, PA
Entity type:Organization
Organization Name:SAWGRASS MILLS MALL DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-846-7171
Mailing Address - Street 1:165 NW 136TH AVE
Mailing Address - Street 2:#C110
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2624
Mailing Address - Country:US
Mailing Address - Phone:954-846-7171
Mailing Address - Fax:954-846-7170
Practice Address - Street 1:165 NW 136TH AVE
Practice Address - Street 2:#C110
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-2624
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:954-846-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty