Provider Demographics
NPI:1215395116
Name:PARADISE LAKES FAMILY DENTIST
Entity Type:Organization
Organization Name:PARADISE LAKES FAMILY DENTIST
Other - Org Name:DR. ALFREDO D. CORPAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:DOMINGO
Authorized Official - Last Name:CORPAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-388-4886
Mailing Address - Street 1:16830 N KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5935
Mailing Address - Country:US
Mailing Address - Phone:305-388-4886
Mailing Address - Fax:305-388-9880
Practice Address - Street 1:16830 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5935
Practice Address - Country:US
Practice Address - Phone:305-388-4886
Practice Address - Fax:305-388-9880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0013451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074855203Medicaid