Provider Demographics
NPI:1407207194
Name:FUNCTIONAL FACIAL ORTHOPEDICS
Entity Type:Organization
Organization Name:FUNCTIONAL FACIAL ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NILSA
Authorized Official - Middle Name:H
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-215-1603
Mailing Address - Street 1:13421 S SHORE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-7210
Mailing Address - Country:US
Mailing Address - Phone:561-215-1603
Mailing Address - Fax:561-537-5738
Practice Address - Street 1:13421 S SHORE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-7210
Practice Address - Country:US
Practice Address - Phone:561-215-1603
Practice Address - Fax:561-537-5738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD17401OtherMEDICAL LICENSE NUMBER
FL075862100Medicaid