=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609656628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GABLES ISMILE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2023
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2725 PONCE DE LEON BLVD
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-396-1026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2725 PONCE DE LEON BLVD
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-396-1026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHEILA RONQUILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-390-5716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------