Provider Demographics
NPI:1063816122
Name:AMERICAN PEDIATRIC DENTAL DORAL, INC
Entity Type:Organization
Organization Name:AMERICAN PEDIATRIC DENTAL DORAL, INC
Other - Org Name:AMERICAN PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS, MBA
Authorized Official - Phone:305-407-2134
Mailing Address - Street 1:7950 NW 53RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4653
Mailing Address - Country:US
Mailing Address - Phone:305-407-2134
Mailing Address - Fax:
Practice Address - Street 1:7950 NW 53RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-4653
Practice Address - Country:US
Practice Address - Phone:305-407-2134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN176081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000641100Medicaid