Provider Demographics
NPI:1568949048
Name:ELENA M SOLIS GONZALEZ DMD LLC
Entity Type:Organization
Organization Name:ELENA M SOLIS GONZALEZ DMD LLC
Other - Org Name:RENAISSANCE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOLIS GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-267-0906
Mailing Address - Street 1:12002 SW 128TH CT STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4643
Mailing Address - Country:US
Mailing Address - Phone:786-776-3328
Mailing Address - Fax:
Practice Address - Street 1:12002 SW 128TH CT STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4643
Practice Address - Country:US
Practice Address - Phone:786-776-3328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELENA M SOLIS GONZALEZ DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN202401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty