Provider Demographics
NPI:1154853927
Name:PEDIATRIC DENTAL CENTER OF BISCAYNE INC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CENTER OF BISCAYNE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MBA
Authorized Official - Phone:786-368-6212
Mailing Address - Street 1:2645 S DOUGLAS RD
Mailing Address - Street 2:SUITE # 703
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2754
Mailing Address - Country:US
Mailing Address - Phone:305-448-3228
Mailing Address - Fax:305-447-8828
Practice Address - Street 1:557 NE 81ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-4519
Practice Address - Country:US
Practice Address - Phone:786-368-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-31
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17284122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid