Basic Information
Provider Information
NPI: 1033559281
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TOMALTY
FirstName: SEAN
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: D.M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6617 BOYNTON BEACH BLVD
Address2:  
City: BOYNTON BEACH
State: FL
PostalCode: 334373526
CountryCode: US
TelephoneNumber: 5617359898
FaxNumber: 5617359877
Practice Location
Address1: 6617 BOYNTON BEACH BLVD
Address2:  
City: BOYNTON BEACH
State: FL
PostalCode: 334373526
CountryCode: US
TelephoneNumber: 5617359898
FaxNumber: 5617359877
Other Information
ProviderEnumerationDate: 07/02/2013
LastUpdateDate: 07/02/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XDN20153FLY Dental ProvidersDentist 

No ID Information.


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