Healthcare Provider Details

I. General information

NPI: 1548683089
Provider Name (Legal Business Name): SIERRA DENTAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 SW 148TH AVE
SOUTHWEST RANCHES FL
33330-2129
US

IV. Provider business mailing address

4849 SW 148TH AVE
SOUTHWEST RANCHES FL
33330-2129
US

V. Phone/Fax

Practice location:
  • Phone: 954-434-1702
  • Fax: 954-689-4828
Mailing address:
  • Phone: 954-434-1702
  • Fax: 954-689-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN0012206
License Number StateFL

VIII. Authorized Official

Name: CARLOS L SIERRA
Title or Position: OWNER
Credential: DDS
Phone: 954-434-1702