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Organization

BANYAN DENTAL SVC PSL, LLC

Active
Organization subpart
No

Provider details

NPI number
Authorized official
JADE E. THOMAS DDS (OWNER)
(772) 344-3300
Entity
Organization

Contact information

Practice address
1707 NW ST. LUCIE W. BLVD, #126, PORT SAINT LUCIE, FL 34986
(772) 344-3300
(772) 344-3301
Mailing address
1707 NW ST. LUCIE W. BLVD, #126, PORT SAINT LUCIE, FL 34986
(772) 344-3300
(772) 344-3301

Taxonomy

Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DN16485
FL

Other

Enumeration date
02/03/2014
Last updated
02/03/2014
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