Pembroke Lakes Mall Dental PA

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

PEMBROKE LAKES MALL DENTAL PA

Practice address

11401 Pines Blvd Ste 220
Pembroke Pines, FL 33026-4104

Phone

(954) 573-1400

NPI assigned

Oct 5, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Rostislav Krasnov, DMD

Title

Owner

Phone

(954) 573-1400

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1664928000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665532800000",
    "number": "1144945882",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11401 PINES BLVD STE 220",
            "city": "PEMBROKE PINES",
            "state": "FL",
            "postal_code": "330264104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11401 PINES BLVD STE 220",
            "city": "PEMBROKE PINES",
            "state": "FL",
            "postal_code": "330264104",
            "telephone_number": "954-573-1400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEMBROKE LAKES MALL DENTAL PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-05",
        "last_updated": "2022-10-12",
        "certification_date": "2022-10-12",
        "status": "A",
        "authorized_official_last_name": "KRASNOV",
        "authorized_official_first_name": "ROSTISLAV",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "954-573-1400",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Pembroke Dental Associates
• Pembroke Lakes Optical Inc
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• Pembroke Pines Ambulatory Surgery Center, LLC
• Pembroke Pines Artificial Kidney Center Inc

• General Practice Dentistry in Pembroke Pines, FL
• Providers in Pembroke Pines, FL by specialty
• General Practice Dentistry in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 12, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.