Provider Demographics
NPI:1912357906
Name:MJ DENTAL OFFICE
Entity Type:Organization
Organization Name:MJ DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:F
Authorized Official - Last Name:GIL ARAUJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-825-7447
Mailing Address - Street 1:2360 W 68TH ST
Mailing Address - Street 2:SUITE 124
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5514
Mailing Address - Country:US
Mailing Address - Phone:305-825-7447
Mailing Address - Fax:786-534-9399
Practice Address - Street 1:2360 W 68TH ST
Practice Address - Street 2:SUITE 124
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5514
Practice Address - Country:US
Practice Address - Phone:305-825-7447
Practice Address - Fax:786-534-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19789122300000X
FLDN20900122300000X
FLDN21842122300000X
FLDH24260124Q00000X
FLDH23064124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015091000Medicaid