Healthcare Provider Details

I. General information

NPI: 1023381183
Provider Name (Legal Business Name): SOUTHLAND MALL DENTAL,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20505 S DIXIE HWY STE 1683
CUTLER BAY FL
33189-1229
US

IV. Provider business mailing address

20505 S DIXIE HWY STE 1683
CUTLER BAY FL
33189-1229
US

V. Phone/Fax

Practice location:
  • Phone: 305-245-0308
  • Fax: 954-846-7170
Mailing address:
  • Phone: 305-245-0308
  • Fax: 954-846-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ROSTISLAV KRASNOV
Title or Position: OWNER
Credential: DDS
Phone: 305-245-0308