Healthcare Provider Details

I. General information

NPI: 1568608875
Provider Name (Legal Business Name): LAGUNA ISLES DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19551 SHERIDAN STREET
PEMBROKE PINES FL
33332
US

IV. Provider business mailing address

19551 SHERIDAN STREET
PEMBROKE PINES FL
33332
US

V. Phone/Fax

Practice location:
  • Phone: 954-680-5552
  • Fax: 954-680-1808
Mailing address:
  • Phone: 954-680-5552
  • Fax: 954-680-1808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN17384
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10651
License Number StateFL

VIII. Authorized Official

Name: DR. MONEEZE MUJTABA
Title or Position: DENTIST
Credential: D.D.S.
Phone: 954-680-5552