MEDICARE: LITTLE SMILES DENTAL OFFICE #1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	DN15894	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154608370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE SMILES DENTAL OFFICE #1

Provider Business Mailing Address
First Line	:	15495 EAGLE NEST LN STE 110
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2242
Country	:	US
Telephone Number	:	305-698-7566
Fax Number	:	305-698-7565

Provider Business Practice Location Address
First Line	:	15495 EAGLE NEST LN STE 110
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2242
Country	:	US
Telephone Number	:	305-698-7566
Fax Number	:	305-698-7565

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. BAYARDO C CORTES
Credential	:	DMD
Telephone Number	:	305-698-7566

Provider Enumeration Date	:	11/16/2011
Last Update Date	:	11/16/2011

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