Provider Demographics
NPI:1073874723
Name:LITTLE SMILES DENTALOFFICE #4
Entity Type:Organization
Organization Name:LITTLE SMILES DENTALOFFICE #4
Other - Org Name:LITTLE SMILES DENTAL # 1
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:E
Authorized Official - Last Name:CORTES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-698-7566
Mailing Address - Street 1:1708 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1708 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6668
Practice Address - Country:US
Practice Address - Phone:561-736-8755
Practice Address - Fax:561-736-3996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE SMILES DENTAL #1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16953261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental