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General NPI Number Information
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NPI Number | 1568784270
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Entity Type | Organization
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Legal Business Name | FORTUNE SMILES, INC.
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Dates
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Enumeration Date | 02/22/2010
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Last Update Date | 11/20/2015
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Provider Practice Location Address
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Address Line | 18543 S DIXIE HWY
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City | CUTLER BAY
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State | FL
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Zip | 33157-6845
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Country | US
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Telephone | 305-259-9210
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Fax | 305-259-9120
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Provider Business Mailing Address
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Address Line | 18543 SOUTH DIXIE HWY
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City | CUTLER BAY
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State | FL
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Zip | 33157-1765
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Country | US
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Telephone | 305-264-0747
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Fax | 305-264-0595
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Authorized Official
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Title or Position | OWNER
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Name | MADELENE MICHELLE TRUJILLO
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Credential | DDS
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Telephone | 305-264-0747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN18770
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License Number State | FL
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