=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609171339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTHODONTIC DENTISTRY OF S FL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2601 S BAYSHORE DR SUITE 760
-----------------------------------------------------
City | COCONUT GROVE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-5417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-857-0990
-----------------------------------------------------
Fax | 305-857-9180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2601 S BAYSHORE DR SUITE 760
-----------------------------------------------------
City | COCONUT GROVE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-5417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-857-0990
-----------------------------------------------------
Fax | 305-857-9180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. IVONNE FAINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-857-0990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DN13965
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------