MEDICARE: MODERN DENTAL BY SMILE, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1811469398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL BY SMILE, PA

Provider Business Mailing Address
First Line	:	8734 NW 151ST TER
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33018-1386
Country	:	US
Telephone Number	:	786-262-0175
Fax Number	:

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	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS ELISEO RUIZ
Credential	:	DMD
Telephone Number	:	786-262-0175

Provider Enumeration Date	:	12/21/2018
Last Update Date	:	12/21/2018

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