Provider Demographics
NPI:1659616233
Name:LITTLE SMILES DENTAL OFFICE #2
Entity Type:Organization
Organization Name:LITTLE SMILES DENTAL OFFICE #2
Other - Org Name:TOOTH FAIRY LAND DBA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BAYARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORTES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-279-4312
Mailing Address - Street 1:10205 SOUTH DIXIE HIGHWAY SUITE 200/201
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156
Mailing Address - Country:US
Mailing Address - Phone:305-279-4312
Mailing Address - Fax:305-596-6632
Practice Address - Street 1:10205 SOUTH DIXIE HIGHWAY SUITE 200/201
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156
Practice Address - Country:US
Practice Address - Phone:305-279-4312
Practice Address - Fax:305-596-6632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2014-07-28
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
FL=========Medicaid