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General NPI Number Information
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NPI Number | 1568608875
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Entity Type | Organization
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Legal Business Name | LAGUNA ISLES DENTAL, LLC
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Dates
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Enumeration Date | 12/17/2008
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 19551 SHERIDAN STREET
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City | PEMBROKE PINES
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State | FL
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Zip | 33332
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Country | US
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Telephone | 954-680-5552
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Fax | 954-680-1808
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Provider Business Mailing Address
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Address Line | 19551 SHERIDAN STREET
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City | PEMBROKE PINES
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State | FL
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Zip | 33332
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Country | US
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Telephone | 954-680-5552
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Fax | 954-680-1808
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MONEEZE MUJTABA
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Credential | D.D.S.
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Telephone | 954-680-5552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN17384
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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 | DN10651
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | FL
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