Healthcare Provider Details

I. General information

NPI: 1811009194
Provider Name (Legal Business Name): MAIN STREET ORTHODONTICS OF MIAMI LAKES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 NW 67 AVE SUITE 110
MIAMI LAKES FL
33014
US

IV. Provider business mailing address

13195 SW 134 ST 2ND FLOOR
MIAMI FL
33186
US

V. Phone/Fax

Practice location:
  • Phone: 305-823-8831
  • Fax:
Mailing address:
  • Phone: 305-274-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 305-274-2499