Healthcare Provider Details

I. General information

NPI: 1598304537
Provider Name (Legal Business Name): GODENTAL SMILE DESIGN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2019
Last Update Date: 12/21/2019
Certification Date: 12/21/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 RUBY AVE STE C
KISSIMMEE FL
34741-7201
US

IV. Provider business mailing address

221 RUBY AVE STE C
KISSIMMEE FL
34741-7201
US

V. Phone/Fax

Practice location:
  • Phone: 407-201-2169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: NATALIA A DIAZ SUAREZ
Title or Position: DENTIST
Credential: DDS
Phone: 727-277-4240