Provider Demographics
NPI:1568608875
Name:LAGUNA ISLES DENTAL, LLC
Entity Type:Organization
Organization Name:LAGUNA ISLES DENTAL, LLC
Other - Org Name:LAGUNA ISLES DENTAL ASSOCIATES, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONEEZE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUJTABA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-680-5552
Mailing Address - Street 1:19551 SHERIDAN STREET
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33332
Mailing Address - Country:US
Mailing Address - Phone:954-680-5552
Mailing Address - Fax:954-680-1808
Practice Address - Street 1:19551 SHERIDAN STREET
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33332
Practice Address - Country:US
Practice Address - Phone:954-680-5552
Practice Address - Fax:954-680-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
FLDN173841223G0001X
FLDN106511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty