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General NPI Number Information
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NPI Number | 1104586973
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Entity Type | Organization
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Legal Business Name | DYNAMIC ANTI-AGING MD CORP
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Dates
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Enumeration Date | 12/21/2021
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Last Update Date | 12/21/2021
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Provider Practice Location Address
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Address Line | 217 SE 1ST ST
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City | MIAMI
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State | FL
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Zip | 33131-1901
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Country | US
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Telephone | 786-803-8843
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Fax | 786-803-8876
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Provider Business Mailing Address
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Address Line | 217 SE 1ST ST
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City | MIAMI
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State | FL
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Zip | 33131-1901
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Country | US
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Telephone | 786-803-8843
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Fax | 786-803-8876
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Authorized Official
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Title or Position | OWNER
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Name | MR. KONSTANTINOS PAPADOPPOULOS
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Credential |
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Telephone | 786-803-8843
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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