=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457546079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST RIVER INTERNATIONAL INC. LLD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2007
-----------------------------------------------------
Last Update Date | 09/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 WASHINGTON AVE SUITE 350
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-604-5707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 WASHINGTON AVE SUITE 350
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-604-5707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING / INSURANCES
-----------------------------------------------------
Name | TAMARA CUEVAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-923-2943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------