Provider Demographics
NPI:1891309514
Name:DENTILIFE FOUR PA
Entity Type:Organization
Organization Name:DENTILIFE FOUR PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CINTHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRADAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-899-1436
Mailing Address - Street 1:5473 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2954
Mailing Address - Country:US
Mailing Address - Phone:954-486-7025
Mailing Address - Fax:
Practice Address - Street 1:5473 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33319-2954
Practice Address - Country:US
Practice Address - Phone:954-486-7025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003823700Medicaid