MEDICARE: AESTHETIC DENTAL 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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1851851968	OTHER		CMS
2	1497372999	OTHER	FL	CMS
3	1194255539	OTHER	FL	CMS

General Provider Information

NPI Number	:	1467260349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC DENTAL PA

Provider Business Mailing Address
First Line	:	9451 SW 192ND DR
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33157-7933
Country	:	US
Telephone Number	:	786-970-9723
Fax Number	:

Provider Business Practice Location Address
First Line	:	15436 NW 77TH CT
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33016-5822
Country	:	US
Telephone Number	:	305-557-5775
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	SANDOR JAVIER VALLS
Credential	:	DMD
Telephone Number	:	305-557-5775

Provider Enumeration Date	:	12/23/2024
Last Update Date	:	12/23/2024

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Directions to “AESTHETIC DENTAL PA ” Practice Location

Language	Start Address	Practice Location

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