=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245038462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IVANOV MIAMI LAKES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16375 NW 67TH AVE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-946-0005
-----------------------------------------------------
Fax | 786-946-0019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16375 NW 67TH AVE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-946-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PAVEL IVANOV
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-240-4016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------