=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386134500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FERNANDEZDENTPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2018
-----------------------------------------------------
Last Update Date | 05/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11776 SW 88TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-873-6051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10985 SW 48TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-6114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-873-6051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. YENY FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-873-6051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN20110
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------