Provider Demographics
NPI:1154653913
Name:MAIN STREET ORTHODONTICS OF MIAMI LAKES, P.A.
Entity Type:Organization
Organization Name:MAIN STREET ORTHODONTICS OF MIAMI LAKES, P.A.
Other - Org Name:MAIN STREET CHILDREN'S DENTISTRY OF MIAMI LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4461
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:305-274-9312
Practice Address - Street 1:15600 NW 67TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2174
Practice Address - Country:US
Practice Address - Phone:305-823-8831
Practice Address - Fax:305-823-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty