Provider Demographics
NPI:1477085983
Name:DENTAL GROUP OF SOUTH FLORIDA IV
Entity Type:Organization
Organization Name:DENTAL GROUP OF SOUTH FLORIDA IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-542-3197
Mailing Address - Street 1:11373 SW 211TH ST STE 10-11
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2245
Mailing Address - Country:US
Mailing Address - Phone:305-542-3197
Mailing Address - Fax:786-713-0959
Practice Address - Street 1:11373 SW 211TH ST STE 10-11
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2245
Practice Address - Country:US
Practice Address - Phone:305-542-3197
Practice Address - Fax:786-713-0959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17638261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076710700Medicaid