Healthcare Provider Details

I. General information

NPI: 1710696612
Provider Name (Legal Business Name): PINES PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 561-336-6560
  • Fax: 561-336-6560
Mailing address:
  • Phone: 561-336-6560
  • Fax: 561-336-6560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MITCHELL MILLER
Title or Position: OWNER
Credential: DDS
Phone: 561-336-6560