Healthcare Provider Details

I. General information

NPI: 1609585066
Provider Name (Legal Business Name): JCL ORAL SURGERY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 SW 88TH ST STE 106
MIAMI FL
33176-1217
US

IV. Provider business mailing address

11020 SW 88TH ST STE 106
MIAMI FL
33176-1217
US

V. Phone/Fax

Practice location:
  • Phone: 305-279-8600
  • Fax:
Mailing address:
  • Phone: 305-279-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JUAN CARLOS LAZO
Title or Position: PRESIDENT
Credential: DMD
Phone: 305-279-8600