Basic Information
| Provider Information | |||||||||
| NPI: | 1508432428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOFIANOS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7628 SIERRA RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334637917 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1021 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | MOORE HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334716206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639460405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2021 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | DN25857 | FL | Y | Dental Providers | Dentist | Dental Public Health |
No ID Information.