Healthcare Provider Details

I. General information

NPI: 1629378203
Provider Name (Legal Business Name): LICETTE FIORDALIZA ESPINAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 SW 116TH AVE
PEMBROKE PINES FL
33025-3771
US

IV. Provider business mailing address

1465 SW 116TH AVE
PEMBROKE PINES FL
33025-3771
US

V. Phone/Fax

Practice location:
  • Phone: 191-740-2618
  • Fax:
Mailing address:
  • Phone: 191-740-2618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: