Provider Demographics
NPI:1073092284
Name:SOUTH FLORIDA DENTAL CARE
Entity Type:Organization
Organization Name:SOUTH FLORIDA DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ELIZABETH PINALES
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-409-9397
Mailing Address - Street 1:922 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3404
Mailing Address - Country:US
Mailing Address - Phone:178-654-2970
Mailing Address - Fax:786-542-9690
Practice Address - Street 1:922 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3404
Practice Address - Country:US
Practice Address - Phone:178-654-2970
Practice Address - Fax:786-542-9690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1790085819Medicaid