Provider Demographics
NPI:1558818625
Name:DENTAL GROUP OF HIALEAH
Entity Type:Organization
Organization Name:DENTAL GROUP OF HIALEAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:DANILO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-456-5722
Mailing Address - Street 1:3750 W 16 AVE
Mailing Address - Street 2:STE 142-AU
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:305-456-5722
Mailing Address - Fax:
Practice Address - Street 1:3750 W 16 AVE
Practice Address - Street 2:STE 142-AU
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-456-5722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN20258OtherFL DENTAL LIC