Healthcare Provider Details

I. General information

NPI: 1174979496
Provider Name (Legal Business Name): CUTLER BAY DENTAL SPECIALTY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20529 OLD CUTLER RD
CUTLER BAY FL
33189-2454
US

IV. Provider business mailing address

13195 SW 134TH ST
MIAMI FL
33186-4461
US

V. Phone/Fax

Practice location:
  • Phone: 305-274-2499
  • Fax:
Mailing address:
  • Phone: 305-274-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 305-274-2499