Provider Demographics
NPI:1386265346
Name:EAST COMMERCIAL CHILDRENS DENTAL
Entity type:Organization
Organization Name:EAST COMMERCIAL CHILDRENS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:772-204-3529
Mailing Address - Street 1:801 SE 6TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-5185
Mailing Address - Country:US
Mailing Address - Phone:772-204-3529
Mailing Address - Fax:
Practice Address - Street 1:2633 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4135
Practice Address - Country:US
Practice Address - Phone:888-601-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154511376OtherNATIONAL PROVIDER IDENTIFICATION