=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942424700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEMBROKE PINES PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 10/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12311 TAFT ST STE 3
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-4384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-431-7199
-----------------------------------------------------
Fax | 954-431-9102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12311 TAFT ST STE 3
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-4384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-431-7199
-----------------------------------------------------
Fax | 954-431-9102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUAN LUIS GARRASTAZU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-431-7199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------