Provider Demographics
NPI:1205182276
Name:PICASSO AESTHETIC AND COSMETIC DENTAL SPA PA
Entity Type:Organization
Organization Name:PICASSO AESTHETIC AND COSMETIC DENTAL SPA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-370-3343
Mailing Address - Street 1:18302 RIDGELINE DR
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9680
Mailing Address - Country:US
Mailing Address - Phone:239-370-3343
Mailing Address - Fax:239-320-3288
Practice Address - Street 1:26649 DUBLIN WOODS CIRCLE
Practice Address - Street 2:JEFFREY RUBIN
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135
Practice Address - Country:US
Practice Address - Phone:239-370-3343
Practice Address - Fax:239-320-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN128521223G0001X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070759700Medicaid