1518337864 NPI number — DENTAL PROFESSIONAL GROUP,INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518337864 NPI number — DENTAL PROFESSIONAL GROUP,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL PROFESSIONAL GROUP,INC
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:
1518337864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15711 SW 59TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33193-5510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-801-1354
Provider Business Mailing Address Fax Number:
786-801-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2740 SW 97TH AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33165-2681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-801-1354
Provider Business Practice Location Address Fax Number:
786-801-1374
Provider Enumeration Date:
09/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TOLEDO
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
786-801-1354

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN 13211 , 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)





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