Provider Demographics
NPI: | 1417450404 |
---|---|
Name: | DORGIS DENTAL, P.A. |
Entity Type: | Organization |
Organization Name: | DORGIS DENTAL, P.A. |
Other - Org Name: | KINDLY DENTAL |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DORGIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GARCIA LOPEZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 305-474-0400 |
Mailing Address - Street 1: | 18652 NW 67TH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HIALEAH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33015-2406 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 305-474-0400 |
Mailing Address - Fax: | 305-474-0094 |
Practice Address - Street 1: | 18652 NW 67TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | HIALEAH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33015 |
Practice Address - Country: | US |
Practice Address - Phone: | 305-474-0400 |
Practice Address - Fax: | 305-474-0094 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-03-15 |
Last Update Date: | 2018-07-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | DN20258 | 261QD0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |