Provider Demographics
NPI:1437510211
Name:SOFIA FONTECILLA DDS PA
Entity Type:Organization
Organization Name:SOFIA FONTECILLA DDS PA
Other - Org Name:COCONUT GROVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTECILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-353-0735
Mailing Address - Street 1:3220 S DIXIE HWY
Mailing Address - Street 2:#101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-3609
Mailing Address - Country:US
Mailing Address - Phone:786-353-0735
Mailing Address - Fax:
Practice Address - Street 1:3220 S DIXIE HWY
Practice Address - Street 2:#101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-3609
Practice Address - Country:US
Practice Address - Phone:786-353-0735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20387261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental