=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073457453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVADENT SMILE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2026
-----------------------------------------------------
Last Update Date | 04/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8700 W FLAGLER ST STE 407
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-721-3934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8700 W FLAGLER ST SUITE 407
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-721-3934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CAROLINA MESA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-422-9130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------