Provider Demographics
NPI:1689681397
Name:AVENTURA PEDIATRIC DEBTISTRY, LLC
Entity Type:Organization
Organization Name:AVENTURA PEDIATRIC DEBTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-935-1613
Mailing Address - Street 1:2797 NE 207TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1471
Mailing Address - Country:US
Mailing Address - Phone:305-935-1613
Mailing Address - Fax:305-935-4258
Practice Address - Street 1:2797 NE 207TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1471
Practice Address - Country:US
Practice Address - Phone:305-935-1613
Practice Address - Fax:305-935-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty