Provider Demographics
NPI:1417592247
Name:DENTAL SPECIALISTS OF HOMESTEAD
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF HOMESTEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-530-8115
Mailing Address - Street 1:10666 FONTAINEBLEAU BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3117
Mailing Address - Country:US
Mailing Address - Phone:305-220-8911
Mailing Address - Fax:
Practice Address - Street 1:190 NW 14TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4240
Practice Address - Country:US
Practice Address - Phone:786-355-4401
Practice Address - Fax:305-220-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP435417372860OtherDRIVERS LICENSE