Healthcare Provider Details

I. General information

NPI: 1487411435
Provider Name (Legal Business Name): LAUDERDALE ISMILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 N STATE ROAD 7
LAUDERDALE LAKES FL
33313-3724
US

IV. Provider business mailing address

2412 N STATE ROAD 7
LAUDERDALE LAKES FL
33313-3724
US

V. Phone/Fax

Practice location:
  • Phone: 954-281-7405
  • Fax: 954-281-7572
Mailing address:
  • Phone: 954-281-7405
  • Fax: 954-281-7572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHEILA RONQUILLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 786-390-5716