Provider Demographics
NPI:1093454431
Name:FUNDORA PELAYO, LILIAN (DMD)
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:
Last Name:FUNDORA PELAYO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SW 27TH AVE APT 706
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3672
Mailing Address - Country:US
Mailing Address - Phone:786-471-7771
Mailing Address - Fax:
Practice Address - Street 1:3631 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4307
Practice Address - Country:US
Practice Address - Phone:305-485-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN269051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice