MEDICARE: SOUTH FLORIDA JAW AND FACIAL SURGERY-DENTAL IMPLANTS CENTER 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1578114443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH FLORIDA JAW AND FACIAL SURGERY-DENTAL IMPLANTS CENTER PA

Provider Business Mailing Address
First Line	:	7600 S RED RD STE 101
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-5429
Country	:	US
Telephone Number	:	305-661-5297
Fax Number	:	305-667-3503

Provider Business Practice Location Address
First Line	:	7600 S RED RD STE 101
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-5429
Country	:	US
Telephone Number	:	305-661-5297
Fax Number	:	305-667-3503

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. MILLIE ACOSTA FERNANDEZ
Credential	:
Telephone Number	:	305-661-5297

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	09/23/2019

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