=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124233648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLORIA YALILE NIETO DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 02/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5937 SHERIDAN ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-589-0750
-----------------------------------------------------
Fax | 954-639-7143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5937 SHERIDAN ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-589-0750
-----------------------------------------------------
Fax | 954-639-7143
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN 16408
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------