Provider Demographics
NPI:1285185090
Name:SOUTH DENTAL AT SUNNY ISLES BEACH INC.
Entity Type:Organization
Organization Name:SOUTH DENTAL AT SUNNY ISLES BEACH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TOBON-ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-224-0848
Mailing Address - Street 1:16850 COLLINS AVE STE 113C
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4237
Mailing Address - Country:US
Mailing Address - Phone:786-707-4757
Mailing Address - Fax:
Practice Address - Street 1:16850 COLLINS AVE STE 113C
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4237
Practice Address - Country:US
Practice Address - Phone:786-707-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty