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General NPI Number Information
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NPI Number | 1922365162
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Entity Type | Organization
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Legal Business Name | SOUTHLAND MALL DENTAL
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Dates
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Enumeration Date | 04/12/2012
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Last Update Date | 04/12/2012
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Provider Practice Location Address
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Address Line | 20505 S DIXIE HWY
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City | CUTLER BAY
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State | FL
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Zip | 33189-1229
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Country | US
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Telephone | 305-232-7982
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Fax | 305-828-7651
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Provider Business Mailing Address
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Address Line | 20505 S DIXIE HWY
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City | CUTLER BAY
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State | FL
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Zip | 33189-1229
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Country | US
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Telephone | 305-232-7982
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Fax | 305-828-7651
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Authorized Official
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Title or Position | OWNER
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Name | DR. VADIM VALDMAN
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Credential | DDS
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Telephone | 212-810-6226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN17761
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License Number State | FL
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