MEDICARE: LAUDERDALE DENTISTRY FOR KIDS 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	1223G0001X	General Practice 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	:	1740756501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUDERDALE DENTISTRY FOR KIDS LLC

Provider Business Mailing Address
First Line	:	4500 N STATE ROAD 7 STE 101
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33319-5868
Country	:	US
Telephone Number	:	954-261-7551
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 N STATE ROAD 7 STE 101
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33319-5868
Country	:	US
Telephone Number	:	954-261-7551
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID TIJERINO
Credential	:	DDS
Telephone Number	:	786-637-4844

Provider Enumeration Date	:	10/19/2018
Last Update Date	:	11/16/2018

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