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General NPI Number Information
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NPI Number | 1720202815
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Entity Type | Organization
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Legal Business Name | DORAL PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 10717 NW 58TH ST
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City | DORAL
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State | FL
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Zip | 33178-2801
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Country | US
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Telephone | 305-513-4058
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Fax | 305-639-2931
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Provider Business Mailing Address
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Address Line | 10717 NW 58TH ST
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City | DORAL
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State | FL
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Zip | 33178-2801
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Country | US
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Telephone | 305-513-4058
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Fax | 305-639-2931
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUAN LUIS GARRASTAZU
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Credential | DMD
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Telephone | 305-513-4058
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State | FL
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