MEDICARE: DENTAL BOOST LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	19159	FL

General Provider Information

NPI Number	:	1083953855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL BOOST LLC

Provider Business Mailing Address
First Line	:	344 W 65TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-6719
Country	:	US
Telephone Number	:	302-822-4607
Fax Number	:

Provider Business Practice Location Address
First Line	:	344 W 65TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-6719
Country	:	US
Telephone Number	:	302-822-4607
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARIANA GABALDON
Credential	:	DDS
Telephone Number	:	305-822-4607

Provider Enumeration Date	:	02/13/2013
Last Update Date	:	02/13/2013

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