Provider Demographics
NPI:1760868863
Name:GATEWAY DENTAL INC
Entity Type:Organization
Organization Name:GATEWAY DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-552-1553
Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-552-1553
Mailing Address - Fax:305-325-0935
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:SUITE 215
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3584
Practice Address - Country:US
Practice Address - Phone:305-552-1553
Practice Address - Fax:305-325-0935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101379200Medicaid