=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760126999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE OF DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2022
-----------------------------------------------------
Last Update Date | 09/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 N FEDERAL HWY STE 210
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-998-2099
-----------------------------------------------------
Fax | 954-556-1799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 N FEDERAL HWY STE 210
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-998-2099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERNESTO GONZALEZ DIAZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 954-998-2099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------