Provider Demographics
NPI:1598513327
Name:SERENITY GROVE DENTAL PLLC
Entity type:Organization
Organization Name:SERENITY GROVE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSOLUPOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-318-0805
Mailing Address - Street 1:1331 DUVAL ST
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-8761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13475 SOUTHERN BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470
Practice Address - Country:US
Practice Address - Phone:561-318-0805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental