Provider Demographics
NPI:1417183013
Name:MIAMI BEACH DENTAL SPECIALTY CENTER LLC
Entity Type:Organization
Organization Name:MIAMI BEACH DENTAL SPECIALTY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-761-1178
Mailing Address - Street 1:900 71ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-2916
Mailing Address - Country:US
Mailing Address - Phone:305-761-1178
Mailing Address - Fax:
Practice Address - Street 1:900 71ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-2916
Practice Address - Country:US
Practice Address - Phone:305-761-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty