Healthcare Provider Details

I. General information

NPI: 1649375254
Provider Name (Legal Business Name): HIALEAH DENTAL SPECIALTY ASSOCIATES, P.L.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W 49TH ST SUITE 400
HIALEAH FL
33012-3402
US

IV. Provider business mailing address

900 W 49TH ST SUITE 400
HIALEAH FL
33012-3402
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-1211
  • Fax: 305-557-6360
Mailing address:
  • Phone: 305-558-1211
  • Fax: 305-557-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDN5112
License Number StateFL

VIII. Authorized Official

Name: DR. ROBERT B CUSHING
Title or Position: MEMBER
Credential: DDS.
Phone: 305-558-1211