=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174498141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVA DENTAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2025
-----------------------------------------------------
Last Update Date | 10/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7208 W SAND LAKE RD STE 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-5277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-319-4005
-----------------------------------------------------
Fax | 321-319-4155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7208 W SAND LAKE RD STE 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-5277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-319-4005
-----------------------------------------------------
Fax | 321-319-4155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PEDRO SPERANDIO LOPES MORALES
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 862-704-9388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------