Provider Demographics
NPI:1811517519
Name:LITWACK, GILI
Entity type:Individual
Prefix:
First Name:GILI
Middle Name:
Last Name:LITWACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5770 WILES RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-2156
Practice Address - Country:US
Practice Address - Phone:954-255-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2025-01-16
Deactivation Date:2024-11-07
Deactivation Code:
Reactivation Date:2024-12-17
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN256751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program