Provider Demographics
NPI:1912395930
Name:TLC DENTAL - AVENTURA, LLC
Entity Type:Organization
Organization Name:TLC DENTAL - AVENTURA, LLC
Other - Org Name:AVENTURA DENTAL GROUP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-650-1122
Mailing Address - Street 1:20475 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20475 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1550
Practice Address - Country:US
Practice Address - Phone:305-935-4030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN85821223G0001X
FLDN156551223G0001X
FLDN192591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty