=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336957216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST CLASS DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2024
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 PONCE DE LEON BLVD STE 401
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-2073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-444-8591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9451 SW 192ND DR
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-7933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-970-9723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | SANDOR JAVIER VALLS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 305-444-8591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------