1205377488 NPI number — ADVANCED ENDODONTIC GROUP

Table of content: (NPI 1205377488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205377488 NPI number — ADVANCED ENDODONTIC GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED ENDODONTIC GROUP
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:
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:
1205377488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16426 NE 32ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33160-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-615-6300
Provider Business Mailing Address Fax Number:
305-330-9902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7975 NW 154TH ST
Provider Second Line Business Practice Location Address:
#250
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-5863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-615-6300
Provider Business Practice Location Address Fax Number:
305-330-9902
Provider Enumeration Date:
03/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
EPELMAN DORRA
Authorized Official First Name:
INGRID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-488-0335

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  DN18918 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101625700 . 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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