Provider Demographics
NPI:1295029700
Name:JACARRENO DDS PA
Entity Type:Organization
Organization Name:JACARRENO DDS PA
Other - Org Name:DENTAL OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CARRENO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-553-1640
Mailing Address - Street 1:10688 CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-7917
Mailing Address - Country:US
Mailing Address - Phone:305-553-1640
Mailing Address - Fax:305-271-1167
Practice Address - Street 1:10688 CORAL WAY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7917
Practice Address - Country:US
Practice Address - Phone:305-553-1640
Practice Address - Fax:305-271-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN72191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty