Provider Demographics
NPI:1699157065
Name:PEMBROKE, KATELYN ALINA (DMD)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ALINA
Last Name:PEMBROKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 NW FLAGLER AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-1158
Mailing Address - Country:US
Mailing Address - Phone:772-215-2876
Mailing Address - Fax:
Practice Address - Street 1:2812 SW MAPP RD
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2722
Practice Address - Country:US
Practice Address - Phone:772-283-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL212101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice