=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073092284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH FLORIDA DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 922 E 25TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33013-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 178-654-2970
-----------------------------------------------------
Fax | 786-542-9690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 922 E 25TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33013-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 178-654-2970
-----------------------------------------------------
Fax | 786-542-9690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WENDY ELIZABETH PINALES SWANSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 305-409-9397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------