Healthcare Provider Details

I. General information

NPI: 1295791085
Provider Name (Legal Business Name): MICHAEL PELEG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE BOX 016960 M851
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE BOX 016960 M851
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1288
  • Fax: 305-243-8470
Mailing address:
  • Phone: 305-585-1288
  • Fax: 305-243-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDTP370
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: