Provider Demographics
NPI:1972703619
Name:ORAL FACIAL RECONSTRUCTION & IMPLANT CENTER OF S. FLORIDA INC.
Entity type:Organization
Organization Name:ORAL FACIAL RECONSTRUCTION & IMPLANT CENTER OF S. FLORIDA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-475-9840
Mailing Address - Street 1:100 NW 82ND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-7809
Mailing Address - Country:US
Mailing Address - Phone:954-475-9840
Mailing Address - Fax:954-370-0500
Practice Address - Street 1:100 NW 82ND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-7809
Practice Address - Country:US
Practice Address - Phone:954-475-9840
Practice Address - Fax:954-370-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21328BMedicare PIN
FL21328Medicare PIN
FL21328AMedicare PIN
FL21328CMedicare PIN