| Entity Name: | LW PEDIATRIC DENTISTRY PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 16 Jan 2020 (5 years ago) |
| Document Number: | P20000003111 |
| FEI/EIN Number | 84-4310883 |
| Address: | 6910 LAKE WORTH RD, lake worth, FL 33467 |
| Mail Address: | 6910 LAKE WORTH RD, lake worth, FL 33467 |
| ZIP code: | 33467 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104450121 | 2020-02-28 | 2020-02-28 | 6910 LAKE WORTH RD, LAKE WORTH, FL, 334672978, US | 6910 LAKE WORTH RD, LAKE WORTH, FL, 334672978, US | |||||||||||||||||||||
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| Phone | +1 561-770-7321 |
| Fax | 5617250762 |
Authorized person
| Name | DR. DREW POPPER |
| Role | OWNER |
| Phone | 2034156875 |
Taxonomy
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 017151100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| POPPER, DREW | Agent | 6910 LAKE WORTH RD, lake worth, FL 33467 |
| Name | Role | Address |
|---|---|---|
| POPPER, DREW | Director | 6910 LAKE WORTH RD, LAKE WORTH, FL 33467 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000067721 | LAKE WORTH PEDIATRIC DENTISTRY | ACTIVE | 2020-06-16 | 2025-12-31 | No data | 1009 W HERITAGE CLUB CIR., DELRAY BEACH, FL, 33483 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2022-01-24 | 6910 LAKE WORTH RD, lake worth, FL 33467 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-07-02 | 6910 LAKE WORTH RD, lake worth, FL 33467 | No data |
| CHANGE OF MAILING ADDRESS | 2020-07-02 | 6910 LAKE WORTH RD, lake worth, FL 33467 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-09 |
| ANNUAL REPORT | 2023-01-24 |
| ANNUAL REPORT | 2022-01-24 |
| ANNUAL REPORT | 2021-01-25 |
| Domestic Profit | 2020-01-16 |
Date of last update: 15 Feb 2025
Sources: Florida Department of State
