=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497145338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICASSO DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2015
-----------------------------------------------------
Last Update Date | 01/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9572 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-388-9229
-----------------------------------------------------
Fax | 305-388-9229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9572 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-388-9229
-----------------------------------------------------
Fax | 305-388-9229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAIKO ROJAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-388-9229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN20138
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------