Healthcare Provider Details

I. General information

NPI: 1205682978
Provider Name (Legal Business Name): LAUREN LOURDES MANTILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5607 NW 27TH AVE STE 2
MIAMI FL
33142-2826
US

IV. Provider business mailing address

5607 NW 27TH AVE STE 1
MIAMI FL
33142-2826
US

V. Phone/Fax

Practice location:
  • Phone: 305-637-6400
  • Fax: 305-636-5155
Mailing address:
  • Phone: 305-805-1700
  • Fax: 305-805-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN29089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: