Healthcare Provider Details

I. General information

NPI: 1730906124
Provider Name (Legal Business Name): PRIME PEDIATRIC DENTAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 W 16TH AVE STE 52
HIALEAH FL
33012-7193
US

IV. Provider business mailing address

4410 W 16TH AVE STE 52
HIALEAH FL
33012-7193
US

V. Phone/Fax

Practice location:
  • Phone: 305-251-5390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSE MELLADO
Title or Position: PRESIDENT
Credential: DMD
Phone: 305-321-3790