Organization
CUSTOM CROWNS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TYSHAWN MARTIN (CEO)
(305) 788-7779
Entity
Organization
Contact information
Practice address
5400 S UNIVERSITY DR, DAVIE, FL 33328-5312
(954) 947-0641
Mailing address
5202 PLUNKETT ST, HOLLYWOOD, FL 33021-8023
(305) 788-7779
Taxonomy
Speciality
Code
Description
License number
State
2080P0006X
Developmental - Behavioral Pediatrics Physician
—
—
246RM2200X
Medical Laboratory Technician
Primary
—
—
247ZC0005X
Clinical Laboratory Director (Non-physician)
—
—
261Q00000X
Clinic/Center
—
—
261QC1500X
Community Health Clinic/Center
—
—
261QH0100X
Health Service Clinic/Center
—
—
261QI0500X
Infusion Therapy Clinic/Center
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
261QX0100X
Occupational Medicine Clinic/Center
—
—
291U00000X
Clinical Medical Laboratory
—
—
Other
Enumeration date
02/04/2022
Last updated
02/04/2022
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