Provider Demographics
NPI:1558709873
Name:INTERNATIONAL DENTAL GROUP
Entity Type:Organization
Organization Name:INTERNATIONAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:RENATE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-558-4100
Mailing Address - Street 1:1030 N ROYAL POINCIANA BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-3257
Mailing Address - Country:US
Mailing Address - Phone:786-558-4100
Mailing Address - Fax:866-305-9918
Practice Address - Street 1:1030 N ROYAL POINCIANA BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-3257
Practice Address - Country:US
Practice Address - Phone:786-558-4100
Practice Address - Fax:866-305-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty