Provider Demographics
NPI:1285227306
Name:FONTELO, LUCIEL (RDH)
Entity Type:Individual
Prefix:
First Name:LUCIEL
Middle Name:
Last Name:FONTELO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 SW 216TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33190
Mailing Address - Country:US
Mailing Address - Phone:305-253-5100
Mailing Address - Fax:305-254-4901
Practice Address - Street 1:6350 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4836
Practice Address - Country:US
Practice Address - Phone:786-293-5500
Practice Address - Fax:786-293-5508
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH27278124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty