Healthcare Provider Details

I. General information

NPI: 1619461639
Provider Name (Legal Business Name): FACIAL SUBTLETIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 ARTHUR GODFREY RD STE 306
MIAMI BEACH FL
33140-3350
US

IV. Provider business mailing address

975 ARTHUR GODFREY RD STE 306
MIAMI BEACH FL
33140-3350
US

V. Phone/Fax

Practice location:
  • Phone: 305-532-1728
  • Fax: 305-532-1729
Mailing address:
  • Phone: 305-532-1728
  • Fax: 305-532-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21820
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number21820
License Number StateFL

VIII. Authorized Official

Name: DR. ANGELA MCMULLIN
Title or Position: PRESIDENT
Credential: DMD
Phone: 609-915-9087