Provider Demographics
NPI:1477894079
Name:BEACH DENTAL SPECIALIST
Entity Type:Organization
Organization Name:BEACH DENTAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDY
Authorized Official - Middle Name:AUGUSTO
Authorized Official - Last Name:GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-424-2705
Mailing Address - Street 1:4011 W FLAGLER ST.
Mailing Address - Street 2:505
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:305-424-2705
Mailing Address - Fax:305-643-0447
Practice Address - Street 1:4011 W FLAGLER ST.
Practice Address - Street 2:505
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:305-424-2705
Practice Address - Fax:305-643-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187771223E0200X
FLDN182531223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty