Provider Demographics
NPI:1629473913
Name:LITTLE SMILES DENTAL OF PALM BEACH
Entity Type:Organization
Organization Name:LITTLE SMILES DENTAL OF PALM BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:BAYARDO
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:CORTES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-736-8755
Mailing Address - Street 1:400 EXECUTIVE CENTER DR
Mailing Address - Street 2:STE 103
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2917
Mailing Address - Country:US
Mailing Address - Phone:561-736-8755
Mailing Address - Fax:561-736-3996
Practice Address - Street 1:400 EXECUTIVE CENTER DR
Practice Address - Street 2:STE 103
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2917
Practice Address - Country:US
Practice Address - Phone:561-736-8755
Practice Address - Fax:561-736-3996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE SMILES DENTAL OFFICE #1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid