Provider Demographics
NPI:1669857462
Name:FLEITAS PERDOMO, YARIELA
Entity Type:Individual
Prefix:
First Name:YARIELA
Middle Name:
Last Name:FLEITAS PERDOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 FOREST HILL BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-6202
Mailing Address - Country:US
Mailing Address - Phone:786-370-0147
Mailing Address - Fax:
Practice Address - Street 1:432 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1021
Practice Address - Country:US
Practice Address - Phone:305-326-7159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026119001223G0001X
FLDN21260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice