Healthcare Provider Details

I. General information

NPI: 1467691212
Provider Name (Legal Business Name): BUENOS AIRES DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 BUENOS AIRES BLVD STE 125
THE VILLAGES FL
32159-6821
US

IV. Provider business mailing address

1503 BUENOS AIRES BLVD STE 125
THE VILLAGES FL
32159-6821
US

V. Phone/Fax

Practice location:
  • Phone: 352-753-5838
  • Fax: 352-391-5837
Mailing address:
  • Phone: 352-753-5838
  • Fax: 352-391-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14668
License Number StateFL

VIII. Authorized Official

Name: DR. PHUONG (HELENE) D TA
Title or Position: PRESIDENT/ OWNER
Credential: DDS
Phone: 352-255-5538