Provider Demographics
NPI:1972164762
Name:TDC JUPITER FARMS, LLC
Entity type:Organization
Organization Name:TDC JUPITER FARMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-777-8980
Mailing Address - Street 1:8794 W BOYNTON BEACH BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4468
Mailing Address - Country:US
Mailing Address - Phone:561-777-8980
Mailing Address - Fax:561-777-8608
Practice Address - Street 1:10156 INDIANTOWN RD STE B7
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-4707
Practice Address - Country:US
Practice Address - Phone:561-743-6700
Practice Address - Fax:561-743-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty