Healthcare Provider Details

I. General information

NPI: 1386062917
Provider Name (Legal Business Name): CARLOS FORS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 07/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE .#2005
MIAMI FL
33136-1003
US

IV. Provider business mailing address

10225 SW 24TH ST APT B425
MIAMI FL
33165-2565
US

V. Phone/Fax

Practice location:
  • Phone: 305-689-6725
  • Fax: 305-689-1133
Mailing address:
  • Phone: 786-209-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22899
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0200000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: