Healthcare Provider Details

I. General information

NPI: 1912318320
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF MIAMI PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9485 SW 72ND ST SUITE A240
MIAMI FL
33173-3242
US

IV. Provider business mailing address

9485 SW 72 STREET SUITE A240
MIAMI FL
33173
US

V. Phone/Fax

Practice location:
  • Phone: 786-360-5401
  • Fax:
Mailing address:
  • Phone: 786-360-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN17737
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN18428
License Number StateFL

VIII. Authorized Official

Name: DR. DEREK SANDERS
Title or Position: OWNER
Credential:
Phone: 305-598-3384