Basic Information
| Provider Information | |||||||||
| NPI: | 1407220726 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TDC FOUNTAINS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6617 W BOYNTON BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334373526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617359898 | ||||||||
| FaxNumber: | 5617359877 | ||||||||
| Practice Location | |||||||||
| Address1: | 6617 W BOYNTON BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334373526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617359898 | ||||||||
| FaxNumber: | 5617359877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2015 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | TOMALTY | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5617359898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.