Provider Demographics
NPI:1003331034
Name:LAURA LONDONO DMD PA
Entity Type:Organization
Organization Name:LAURA LONDONO DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LONDONO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-554-6309
Mailing Address - Street 1:4147 OPEN WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1154
Mailing Address - Country:US
Mailing Address - Phone:786-554-6309
Mailing Address - Fax:
Practice Address - Street 1:7800 N UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2113
Practice Address - Country:US
Practice Address - Phone:954-670-1170
Practice Address - Fax:786-554-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20878261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL661726Medicaid