Provider Demographics
NPI:1174859896
Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS AT LONDON SQUARE, PA
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS AT LONDON SQUARE, PA
Other - Org Name:DENTAL ASSOCIATES OF WEST KENDALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134TH ST FL 2
Mailing Address - Street 2:
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 1:13400 SW 120TH ST
Practice Address - Street 2:STE 310
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7440
Practice Address - Country:US
Practice Address - Phone:305-255-9541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN5380122300000X
1223G0001X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty