Healthcare Provider Details

I. General information

NPI: 1609494137
Provider Name (Legal Business Name): SANDORF MONTERO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 NW 87TH CT STE 166
HIALEAH GARDENS FL
33018-4521
US

IV. Provider business mailing address

11300 NW 87TH CT STE 166
HIALEAH GARDENS FL
33018-4521
US

V. Phone/Fax

Practice location:
  • Phone: 786-702-5643
  • Fax: 305-364-0983
Mailing address:
  • Phone: 786-702-5643
  • Fax: 305-364-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN25173
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN25173
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: