=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154918498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI DENTAL GROUP WEST KENDALL PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2020
-----------------------------------------------------
Last Update Date | 12/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2648 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-551-1309
-----------------------------------------------------
Fax | 305-551-1303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7755 SW 87TH AVE STE 120
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-271-0160
-----------------------------------------------------
Fax | 305-271-4111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DANNY PENA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 305-271-0160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------