Provider Demographics
NPI:1396043576
Name:MGM DENTAL PA
Entity Type:Organization
Organization Name:MGM DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:GABRIELA
Authorized Official - Last Name:MOGOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-597-1636
Mailing Address - Street 1:15659 SW 88TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1103
Mailing Address - Country:US
Mailing Address - Phone:786-558-7315
Mailing Address - Fax:786-558-7318
Practice Address - Street 1:15659 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196
Practice Address - Country:US
Practice Address - Phone:786-558-7315
Practice Address - Fax:786-558-7318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
FLDN20484261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty