Provider Demographics
NPI:1538510862
Name:ADVANTAGE DENTAL ESTHETIC GROUP
Entity Type:Organization
Organization Name:ADVANTAGE DENTAL ESTHETIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-384-7505
Mailing Address - Street 1:17130 ROYAL PALM BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2311
Mailing Address - Country:US
Mailing Address - Phone:954-384-7505
Mailing Address - Fax:954-384-2465
Practice Address - Street 1:17130 ROYAL PALM BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2311
Practice Address - Country:US
Practice Address - Phone:954-384-7505
Practice Address - Fax:954-384-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN126341223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty