=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922685973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2021
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 UNIVERSITY DR
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-520-7822
-----------------------------------------------------
Fax | 786-289-9828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 UNIVERSITY DR
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-520-7822
-----------------------------------------------------
Fax | 786-289-9828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | DR. NICHOLAS ANDRES CASTELLANOS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 305-520-7822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------