Provider Demographics
NPI:1871012633
Name:MERCY DENTAL CORP
Entity Type:Organization
Organization Name:MERCY DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-406-9241
Mailing Address - Street 1:14749 SW 102ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1629
Mailing Address - Country:US
Mailing Address - Phone:786-406-9241
Mailing Address - Fax:
Practice Address - Street 1:3172 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-3001
Practice Address - Country:US
Practice Address - Phone:786-406-9241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21847261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental