Healthcare Provider Details

I. General information

NPI: 1972492411
Provider Name (Legal Business Name): FUNDROA DENTAL SMILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8740 N KENDALL DR STE 220
MIAMI FL
33176-2221
US

IV. Provider business mailing address

8740 N KENDALL DR STE 220
MIAMI FL
33176-2221
US

V. Phone/Fax

Practice location:
  • Phone: 305-270-8029
  • Fax: 305-273-8437
Mailing address:
  • Phone: 305-270-8029
  • 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: DR. JELSEY FUNDORA
Title or Position: GENERAL DENTIST
Credential:
Phone: 786-317-1337