Healthcare Provider Details

I. General information

NPI: 1699446633
Provider Name (Legal Business Name): KEY WEST DENTAL MANAGEMENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SIMONTON ST
KEY WEST FL
33040-3158
US

IV. Provider business mailing address

1215 SIMONTON ST
KEY WEST FL
33040-3158
US

V. Phone/Fax

Practice location:
  • Phone: 305-296-8541
  • Fax:
Mailing address:
  • Phone: 305-296-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ISIS SAMPEDRO
Title or Position: C.O.O
Credential:
Phone: 786-226-7474