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General NPI Number Information
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NPI Number | 1689794505
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Entity Type | Organization
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Legal Business Name | CORAL RIDGE SMILE
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 02/16/2012
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Provider Practice Location Address
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Address Line | 2324 NE 53RD ST
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City | FT LAUDERDALE
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State | FL
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Zip | 33308-3212
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Country | US
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Telephone | 954-990-6543
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Fax | 954-491-4876
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Provider Business Mailing Address
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Address Line | 2324 NE 53RD ST.
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City | FT. LAUDERDALE
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State | FL
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Zip | 33308
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Country | US
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Telephone | 954-990-6543
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Fax | 954-941-4876
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Authorized Official
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Title or Position | OWNER
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Name | DR. MANDANA MIR ESMAILI
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Credential | D.D.S.
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Telephone | 954-990-6543
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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 |
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License Number State |
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