=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881888469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHDADE FAMILY DENTISRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 06/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18543 S DIXIE HWY
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-6815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-259-9130
-----------------------------------------------------
Fax | 305-259-9120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18543 S DIXIE HWY
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-6845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-259-9130
-----------------------------------------------------
Fax | 305-259-9120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | ALFREDO DOMINGO CORPAS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 305-259-9130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------