=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740615418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL SPECIALISTS OF CORAL GABLES GROUP CO.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2013
-----------------------------------------------------
Last Update Date | 09/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2645 SW 37TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-305-9601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2645 SW 37TH AVE STE 303
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-305-9601
-----------------------------------------------------
Fax | 305-593-6520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTARTOR
-----------------------------------------------------
Name | MRS. EVELYN MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-305-9601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN10709
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------