=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497134902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOOP SMILE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2015
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7902 NW 36TH ST STE 209
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-477-7655
-----------------------------------------------------
Fax | 305-477-7654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7902 NW 36TH ST STE 209
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-477-7655
-----------------------------------------------------
Fax | 305-477-7654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUAN RICARDO YOUSSEF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-477-7655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN18386
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------