=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306433065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR QUESADA & ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2020
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6267 W SAMPLE RD
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-3175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-341-4766
-----------------------------------------------------
Fax | 954-255-8131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6267 W SAMPLE RD
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-3175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-341-4766
-----------------------------------------------------
Fax | 954-255-8131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LEADING DENTIST
-----------------------------------------------------
Name | DR. PEDRO QUESADA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 786-231-9259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------