MEDICARE: INTERNATIONAL DENTAL CLINIC, PA

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	1223G0001X	General Practice Dentistry	DN11609	FL

General Provider Information

NPI Number	:	1346629292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNATIONAL DENTAL CLINIC, PA

Provider Business Mailing Address
First Line	:	9100 SW 24TH ST STE 4
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-2066
Country	:	US
Telephone Number	:	786-401-6798
Fax Number	:

Provider Business Practice Location Address
First Line	:	9100 SW 24TH ST STE 4
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-2066
Country	:	US
Telephone Number	:	786-401-6798
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FILIBERTO J HERDOCIA
Credential	:	DDS
Telephone Number	:	786-401-6798

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/26/2015

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