Healthcare Provider Details

I. General information

NPI: 1265809107
Provider Name (Legal Business Name): ILIEG OLIVA PEREZ D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2332 SW 82ND CT
MIAMI FL
33155-1247
US

IV. Provider business mailing address

960 SW 72ND AVE
MIAMI FL
33144-4638
US

V. Phone/Fax

Practice location:
  • Phone: 305-202-4979
  • Fax:
Mailing address:
  • Phone: 305-202-4979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 21522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: