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General NPI Number Information
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NPI Number | 1780093781
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Entity Type | Organization
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Legal Business Name | SAMAR DENTAL GROUP
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Dates
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Enumeration Date | 08/05/2014
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Last Update Date | 08/05/2014
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Provider Practice Location Address
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Address Line | 8601 NW 58TH ST UNIT 102
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City | DORAL
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State | FL
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Zip | 33166-3312
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Country | US
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Telephone | 786-261-1163
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Fax |
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Provider Business Mailing Address
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Address Line | 8500 SW 109TH AVE APT 212
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City | MIAMI
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State | FL
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Zip | 33173-4458
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Country | US
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Telephone | 786-261-1163
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LUIS C COLLAZOS
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Credential | D.M.D
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Telephone | 786-261-1163
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 20855
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License Number State | FL
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