Provider Demographics
NPI:1043677925
Name:JACARANDA SMILES EAST
Entity Type:Organization
Organization Name:JACARANDA SMILES EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:LANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-251-2717
Mailing Address - Street 1:10051 PINES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6186
Mailing Address - Country:US
Mailing Address - Phone:954-251-2717
Mailing Address - Fax:954-613-4005
Practice Address - Street 1:10051 PINES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6186
Practice Address - Country:US
Practice Address - Phone:954-251-2717
Practice Address - Fax:954-613-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003557500Medicaid