MEDICARE: KIDS DENTAL PLUS, P.A.

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528722436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS DENTAL PLUS, P.A.

Provider Business Mailing Address
First Line	:	2910 N STATE ROAD 7
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-1912
Country	:	US
Telephone Number	:	954-533-9639
Fax Number	:	954-368-4316

Provider Business Practice Location Address
First Line	:	2910 N STATE ROAD 7
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-1912
Country	:	US
Telephone Number	:	954-533-9639
Fax Number	:	954-368-4316

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RUBEN VILLARREAL
Credential	:	DMD
Telephone Number	:	954-533-9639

Provider Enumeration Date	:	10/26/2021
Last Update Date	:	11/01/2021

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