1184861981 NPI number — THE FAMILY DENTAL CARE CENTER

Table of content: (NPI 1184861981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184861981 NPI number — THE FAMILY DENTAL CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FAMILY DENTAL CARE CENTER
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:
Provider Other Organization Name Type Code:
6
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:
1184861981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
646 W PALM DR
Provider Second Line Business Mailing Address:
202
Provider Business Mailing Address City Name:
HOMESTEAD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33034-3208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-242-1200
Provider Business Mailing Address Fax Number:
305-242-8782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
646 W PALM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33034-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-242-1200
Provider Business Practice Location Address Fax Number:
305-242-8782
Provider Enumeration Date:
01/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DE LA CRUZ
Authorized Official First Name:
ALEJANDRO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-242-1200

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070376101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0755532 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015403000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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