Provider Demographics
NPI:1821610395
Name:KLSIRAGE LLC
Entity Type:Organization
Organization Name:KLSIRAGE LLC
Other - Org Name:MIRAGE DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:LORENZO
Authorized Official - Last Name:SIRAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-223-9795
Mailing Address - Street 1:8688 SUNSET DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:305-482-3559
Mailing Address - Fax:
Practice Address - Street 1:8688 SW 72 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:305-482-3559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty