Healthcare Provider Details

I. General information

NPI: 1811480528
Provider Name (Legal Business Name): YILAIDIS VILLALOBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 NE 2ND AVE
EL PORTAL FL
33138-3001
US

IV. Provider business mailing address

8335 SW 152ND AVE APT B-102
MIAMI FL
33193-4015
US

V. Phone/Fax

Practice location:
  • Phone: 305-758-5878
  • Fax: 786-991-9371
Mailing address:
  • Phone: 305-219-6003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN25336
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: