Healthcare Provider Details

I. General information

NPI: 1487414405
Provider Name (Legal Business Name): ANDREA CAROLINA LEON HOSTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17767 SW 2ND ST
PEMBROKE PINES FL
33029-3924
US

IV. Provider business mailing address

429 N UNIVERSITY DR
PLANTATION FL
33324-1478
US

V. Phone/Fax

Practice location:
  • Phone: 954-430-4334
  • Fax:
Mailing address:
  • Phone: 786-239-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31609
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: