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General NPI Number Information
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NPI Number | 1396043576
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Entity Type | Organization
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Legal Business Name | MGM DENTAL PA
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Dates
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Enumeration Date | 03/11/2011
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Last Update Date | 07/02/2018
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Provider Practice Location Address
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Address Line | 15659 SW 88TH ST
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City | MIAMI
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State | FL
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Zip | 33196
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Country | US
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Telephone | 786-558-7315
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Fax | 786-558-7318
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Provider Business Mailing Address
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Address Line | 15659 SW 88TH ST
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City | MIAMI
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State | FL
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Zip | 33196-1103
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Country | US
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Telephone | 786-558-7315
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Fax | 786-558-7318
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Authorized Official
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Title or Position | OWNER
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Name | MARIA GABRIELA MOGOLLON
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Credential | DDS
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Telephone | 786-597-1636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN20484
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License Number State | FL
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