=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952933590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUDMILA TESORO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 04/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10887 NW 17TH ST
-----------------------------------------------------
City | SWEETWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-2060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-815-0268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19030 NW 10TH ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-465-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN27444
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------