Provider Demographics
NPI:1679106488
Name:DE AGUIAR, LETICIA M
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:M
Last Name:DE AGUIAR
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 1:750 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3817
Mailing Address - Country:US
Mailing Address - Phone:305-694-5400
Mailing Address - Fax:
Practice Address - Street 1:17901 NW 5TH ST STE 202
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2810
Practice Address - Country:US
Practice Address - Phone:954-505-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27249122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist