1154653913 NPI number — MAIN STREET ORTHODONTICS OF MIAMI LAKES, P.A.

Table of content: (NPI 1154653913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154653913 NPI number — MAIN STREET ORTHODONTICS OF MIAMI LAKES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET ORTHODONTICS OF MIAMI LAKES, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAIN STREET CHILDREN'S DENTISTRY OF MIAMI LAKES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154653913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13195 SW 134TH ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186-4461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-274-2499
Provider Business Mailing Address Fax Number:
305-274-9312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15600 NW 67TH AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33014-2174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-823-8831
Provider Business Practice Location Address Fax Number:
305-823-8799
Provider Enumeration Date:
02/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOBER
Authorized Official First Name:
MELVYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
305-274-2499

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)