Healthcare Provider Details

I. General information

NPI: 1104417153
Provider Name (Legal Business Name): MODERNA SMILE OF GALLOWAY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8718 SW 72ND ST
MIAMI FL
33173-3512
US

IV. Provider business mailing address

5246 SW 8TH ST
CORAL GABLES FL
33134-2375
US

V. Phone/Fax

Practice location:
  • Phone: 305-273-9330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUAN CARLOS IZQUIERDO
Title or Position: PRESIDENT
Credential: DMD
Phone: 305-273-9330