Provider Demographics
NPI:1740756501
Name:LAUDERDALE DENTISTRY FOR KIDS LLC
Entity Type:Organization
Organization Name:LAUDERDALE DENTISTRY FOR KIDS LLC
Other - Org Name:LAUDERDALE DENTISTRY FOR KIDS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TIJERINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-637-4844
Mailing Address - Street 1:4500 N STATE ROAD 7 STE 101
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5868
Mailing Address - Country:US
Mailing Address - Phone:954-261-7551
Mailing Address - Fax:
Practice Address - Street 1:4500 N STATE ROAD 7 STE 101
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5868
Practice Address - Country:US
Practice Address - Phone:954-261-7551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty