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General NPI Number Information
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NPI Number | 1710346218
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Entity Type | Organization
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Legal Business Name | PRIVATE PRACTICE PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 02/12/2016
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Last Update Date | 02/12/2016
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Provider Practice Location Address
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Address Line | CALLE 7 # 39-290 OFICINA 901
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City | MEDELLIN
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State | ANTIOQUIA
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Zip | 9999999
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Country | CO
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Telephone | 574-332-0454
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Fax |
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Provider Business Mailing Address
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Address Line | CALLE 7 # 39-290 OFICINA 901
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City | MEDELLIN
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State | ANTIOQUIA
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Zip | 9999999
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Country | CO
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Telephone | 574-332-0454
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. ANTONIO DARIO CARDENAS
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Credential | DDS, MSC
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Telephone | 574-332-0454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2709
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License Number State | ZZ
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