Healthcare Provider Details

I. General information

NPI: 1104586973
Provider Name (Legal Business Name): DYNAMIC ANTI-AGING MD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SE 1ST ST
MIAMI FL
33131-1901
US

IV. Provider business mailing address

217 SE 1ST ST
MIAMI FL
33131-1901
US

V. Phone/Fax

Practice location:
  • Phone: 786-803-8843
  • Fax: 786-803-8876
Mailing address:
  • Phone: 786-803-8843
  • Fax: 786-803-8876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MR. KONSTANTINOS PAPADOPPOULOS
Title or Position: OWNER
Credential:
Phone: 786-803-8843