=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629791553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUPO DENTAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2022
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9633 W BROWARD BLVD STE 10
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33324-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-829-3934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18177 SW 4TH CT
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-4350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-829-3934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST / PRESIDENT
-----------------------------------------------------
Name | DR. YUSIMY PUPO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 954-829-3934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------