Healthcare Provider Details

I. General information

NPI: 1164151031
Provider Name (Legal Business Name): MAGIC LITTLE TEETH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7036 CORAL WAY
MIAMI FL
33155-1603
US

IV. Provider business mailing address

7036 CORAL WAY
MIAMI FL
33155-1603
US

V. Phone/Fax

Practice location:
  • Phone: 305-441-7700
  • Fax:
Mailing address:
  • Phone: 305-441-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. FERNANDO PINO RIVERA
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 305-588-7545