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General NPI Number Information
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NPI Number | 1558663906
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Entity Type | Organization
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Legal Business Name | MIAMI GARDENS DENTAL,INC
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Dates
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Enumeration Date | 11/17/2010
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Last Update Date | 11/17/2010
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Provider Practice Location Address
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Address Line | 4538 NW 183RD ST
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City | MIAMI GARDENS
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State | FL
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Zip | 33055-3045
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Country | US
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Telephone | 305-625-8272
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Fax |
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Provider Business Mailing Address
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Address Line | 4538 NW 183RD ST
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City | MIAMI GARDENS
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State | FL
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Zip | 33055-3045
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Country | US
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Telephone | 305-625-8272
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LUISA Y CORRALES-IGLESIAS
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Credential | D.D.S
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Telephone | 305-625-8272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN17100
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN17100
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License Number State | FL
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