Healthcare Provider Details

I. General information

NPI: 1609538388
Provider Name (Legal Business Name): ADVANCED DENTISTRY OF CORAL SPRINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 10/09/2021
Certification Date: 10/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 N UNIVERSITY DR STE B
CORAL SPRINGS FL
33071-6184
US

IV. Provider business mailing address

2232 N UNIVERSITY DR STE B
CORAL SPRINGS FL
33071-6184
US

V. Phone/Fax

Practice location:
  • Phone: 954-997-5147
  • Fax: 954-692-6496
Mailing address:
  • Phone: 954-997-5147
  • Fax: 954-692-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. RENAN BUITRAGO
Title or Position: PRESIDENT
Credential: DDS
Phone: 917-574-3822