MEDICARE: AMERICAN PEDIATRIC DENTAL PINES LLC

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	1223P0221X	Pediatric Dentistry

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	:	1508396847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN PEDIATRIC DENTAL PINES LLC

Provider Business Mailing Address
First Line	:	18501 PINES BLVD STE 211
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1420
Country	:	US
Telephone Number	:	954-417-1337
Fax Number	:	954-417-1338

Provider Business Practice Location Address
First Line	:	18501 PINES BLVD STE 211
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1420
Country	:	US
Telephone Number	:	954-417-1337
Fax Number	:	954-417-1338

Authorized Official
Title or Position	:	DIRECTOR OF CORPORATE
Name	:	RICHELLE PENA
Credential	:
Telephone Number	:	415-518-5117

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	07/21/2022

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