Provider Demographics
NPI:1699913111
Name:FAMILY DENTIST OF PALM BEACH
Entity type:Organization
Organization Name:FAMILY DENTIST OF PALM BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRIVOLU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-795-7668
Mailing Address - Street 1:11903 SOUTHERN BLVD
Mailing Address - Street 2:STE 116
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7644
Mailing Address - Country:US
Mailing Address - Phone:561-795-7668
Mailing Address - Fax:
Practice Address - Street 1:11903 SOUTHERN BLVD
Practice Address - Street 2:STE 116
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-7644
Practice Address - Country:US
Practice Address - Phone:561-795-7668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158711223G0001X
FLDN129431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty