=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093529604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AURA DENTAL FAMILY PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2025
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3129 PANGEA CIR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-485-3317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 BARNES BLVD
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-485-3317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. GLADYSBEL NMN JIMENEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 347-485-3317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------