=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760911861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ODELSIS BARRERO DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2017
-----------------------------------------------------
Last Update Date | 06/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 W CANAL ST N STE A
-----------------------------------------------------
City | BELLE GLADE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33430-3078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-996-6165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7565 SW 153RD CT APT 102
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-304-6579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22603
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------