Provider Demographics
NPI:1477988442
Name:DENTAL SPECIALISTS OF DORAL GROUP
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF DORAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-355-4401
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:786-355-4401
Mailing Address - Fax:
Practice Address - Street 1:10666 FONTAINEBLEAU BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3117
Practice Address - Country:US
Practice Address - Phone:786-355-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty