Provider Demographics
NPI:1164685996
Name:SOUTH DENTAL DORAL, SPA, INC
Entity Type:Organization
Organization Name:SOUTH DENTAL DORAL, SPA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPENHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-388-7599
Mailing Address - Street 1:3655 NW 107TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4327
Mailing Address - Country:US
Mailing Address - Phone:305-388-7599
Mailing Address - Fax:305-388-1315
Practice Address - Street 1:3655 NW 107TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4327
Practice Address - Country:US
Practice Address - Phone:305-388-7599
Practice Address - Fax:305-388-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty