Provider Demographics
NPI:1023381183
Name:SOUTHLAND MALL DENTAL,P.A.
Entity Type:Organization
Organization Name:SOUTHLAND MALL DENTAL,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-245-0308
Mailing Address - Street 1:20505 S DIXIE HWY
Mailing Address - Street 2:STE 1683
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-1229
Mailing Address - Country:US
Mailing Address - Phone:305-245-0308
Mailing Address - Fax:954-846-7170
Practice Address - Street 1:20505 S DIXIE HWY
Practice Address - Street 2:STE 1683
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-1229
Practice Address - Country:US
Practice Address - Phone:305-245-0308
Practice Address - Fax:954-846-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty