Provider Demographics
NPI:1497001259
Name:MIAMI LAKES PERIODONTAL AND COSMETIC CENTER
Entity Type:Organization
Organization Name:MIAMI LAKES PERIODONTAL AND COSMETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEL
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMS
Authorized Official - Phone:305-556-7010
Mailing Address - Street 1:7735 NW 146TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1583
Mailing Address - Country:US
Mailing Address - Phone:305-556-7010
Mailing Address - Fax:305-231-3984
Practice Address - Street 1:7735 NW 146TH ST STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1583
Practice Address - Country:US
Practice Address - Phone:305-556-7010
Practice Address - Fax:305-231-3984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty