Healthcare Provider Details

I. General information

NPI: 1760126999
Provider Name (Legal Business Name): VILLAGE OF DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N FEDERAL HWY STE 210
HALLANDALE BEACH FL
33009-2451
US

IV. Provider business mailing address

701 N FEDERAL HWY STE 210
HALLANDALE BEACH FL
33009-2451
US

V. Phone/Fax

Practice location:
  • Phone: 954-998-2099
  • Fax: 954-556-1799
Mailing address:
  • Phone: 954-998-2099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ERNESTO GONZALEZ DIAZ
Title or Position: OWNER
Credential: DDS
Phone: 954-998-2099