MEDICARE: MODERN DENTAL 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	122300000X	Dentist	DN12245	FL

General Provider Information

NPI Number	:	1649451022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL CENTER, PA

Provider Business Mailing Address
First Line	:	8221 W FLAGLER ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2027
Country	:	US
Telephone Number	:	305-266-7000
Fax Number	:	305-261-0397

Provider Business Practice Location Address
First Line	:	8221 W FLAGLER ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2027
Country	:	US
Telephone Number	:	305-266-7000
Fax Number	:	305-261-0397

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. CIRO ANTONIO SOTOMAYOR III
Credential	:	DDS
Telephone Number	:	305-266-7000

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	11/14/2007

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