=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962556514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINES FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20170 PINES BLVD STE 108
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-430-1717
-----------------------------------------------------
Fax | 954-430-3049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20170 PINES BLVD STE 108
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-430-1717
-----------------------------------------------------
Fax | 954-430-3049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAUL LIZASO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-430-1717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN001496
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------