Provider Demographics
NPI:1710346218
Name:PRIVATE PRACTICE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PRIVATE PRACTICE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:CARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSC
Authorized Official - Phone:574-332-0454
Mailing Address - Street 1:CALLE 7 # 39-290
Mailing Address - Street 2:OFICINA 901
Mailing Address - City:MEDELLIN
Mailing Address - State:ANTIOQUIA
Mailing Address - Zip Code:9999999
Mailing Address - Country:CO
Mailing Address - Phone:574-332-0454
Mailing Address - Fax:
Practice Address - Street 1:CALLE 7 # 39-290
Practice Address - Street 2:OFICINA 901
Practice Address - City:MEDELLIN
Practice Address - State:ANTIOQUIA
Practice Address - Zip Code:9999999
Practice Address - Country:CO
Practice Address - Phone:574-332-0454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2709261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center