Provider Demographics
NPI:1891407011
Name:CHILDRENS DENTISTRY OF AMERICA HOMESTEAD LLC
Entity Type:Organization
Organization Name:CHILDRENS DENTISTRY OF AMERICA HOMESTEAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GISLEDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:772-485-9759
Mailing Address - Street 1:311 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4738
Mailing Address - Country:US
Mailing Address - Phone:954-775-0723
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4738
Practice Address - Country:US
Practice Address - Phone:954-775-0723
Practice Address - Fax:754-241-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101344800Medicaid