Basic Information
Provider Information
NPI: 1033248554
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SCERBO
FirstName: PETER
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 19390 COLLINS AVE
Address2: #201A
City: SUNNY ISLES BEACH
State: FL
PostalCode: 331602200
CountryCode: US
TelephoneNumber: 3059369381
FaxNumber:  
Practice Location
Address1: 6600 W 12TH AVE
Address2:  
City: HIALEAH
State: FL
PostalCode: 330126450
CountryCode: US
TelephoneNumber: 3058212611
FaxNumber: 3055560746
Other Information
ProviderEnumerationDate: 03/02/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001XDN16840FLY Dental ProvidersDentistGeneral Practice

No ID Information.


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