Healthcare Provider Details

I. General information

NPI: 1417417726
Provider Name (Legal Business Name): ACUARIO DENTAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 W 16TH AVE STE B&205A
HIALEAH FL
33012-7666
US

IV. Provider business mailing address

16547 FOREST LAKE DR
TAMPA FL
33624-1204
US

V. Phone/Fax

Practice location:
  • Phone: 786-800-9507
  • Fax: 305-928-1147
Mailing address:
  • Phone: 813-210-0982
  • Fax: 305-928-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNY M SEGARRA
Title or Position: PRESIDENT
Credential:
Phone: 813-210-0982