MEDICARE: FACIAL SUBTLETIES

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	21820	FL
2	122300000X	Dentist	DN21820	FL

General Provider Information

NPI Number	:	1619461639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FACIAL SUBTLETIES

Provider Business Mailing Address
First Line	:	975 ARTHUR GODFREY RD STE 306
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-3350
Country	:	US
Telephone Number	:	305-532-1728
Fax Number	:	305-532-1729

Provider Business Practice Location Address
First Line	:	975 ARTHUR GODFREY RD STE 306
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-3350
Country	:	US
Telephone Number	:	305-532-1728
Fax Number	:	305-532-1729

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANGELA MCMULLIN
Credential	:	DMD
Telephone Number	:	609-915-9087

Provider Enumeration Date	:	06/22/2018
Last Update Date	:	06/22/2018

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Directions to “FACIAL SUBTLETIES ” Practice Location

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