MEDICARE: SOUTHDADE FAMILY DENTISRY

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

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881888469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHDADE FAMILY DENTISRY

Provider Business Mailing Address
First Line	:	18543 S DIXIE HWY
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33157-6845
Country	:	US
Telephone Number	:	305-259-9130
Fax Number	:	305-259-9120

Provider Business Practice Location Address
First Line	:	18543 S DIXIE HWY
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33157-6815
Country	:	US
Telephone Number	:	305-259-9130
Fax Number	:	305-259-9120

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	ALFREDO DOMINGO CORPAS
Credential	:	DDS
Telephone Number	:	305-259-9130

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	06/06/2014

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