Healthcare Provider Details

I. General information

NPI: 1205921004
Provider Name (Legal Business Name): MARIO JAVIER CABALLERO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 S. PATRICK DRIVE (BUILDING 1371)
PATRICK AIR FORCE BASE FL
32925-3607
US

IV. Provider business mailing address

1389 S. PATRICK DRIVE (BUILDING 1371)
PATRICK AIR FORCE BASE FL
32925-3607
US

V. Phone/Fax

Practice location:
  • Phone: 305-446-5676
  • Fax: 305-446-5265
Mailing address:
  • Phone: 305-446-5676
  • Fax: 305-446-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN11572
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN-11572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: