Provider Demographics
NPI:1538519319
Name:LOURDES
Entity Type:Organization
Organization Name:LOURDES
Other - Org Name:CANO FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-538-6868
Mailing Address - Street 1:680 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6738
Mailing Address - Country:US
Mailing Address - Phone:954-538-6868
Mailing Address - Fax:954-538-6850
Practice Address - Street 1:680 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6738
Practice Address - Country:US
Practice Address - Phone:954-538-6868
Practice Address - Fax:954-538-6850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL604782Medicaid