Provider Demographics
NPI:1275159378
Name:FUENTES FALCON, FLAVIO
Entity Type:Individual
Prefix:DR
First Name:FLAVIO
Middle Name:
Last Name:FUENTES FALCON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19610 NW 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1862
Mailing Address - Country:US
Mailing Address - Phone:786-442-8301
Mailing Address - Fax:
Practice Address - Street 1:5711 SW 137TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-1103
Practice Address - Country:US
Practice Address - Phone:786-442-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist