=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184167389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW SMILE DENTAL SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2016
-----------------------------------------------------
Last Update Date | 11/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 NW 7 ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-444-8863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 NW 7TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-444-8863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANA CABALLERO
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 305-444-8863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN20363
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------