Provider Demographics
NPI:1922365162
Name:SOUTHLAND MALL DENTAL
Entity Type:Organization
Organization Name:SOUTHLAND MALL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-810-6226
Mailing Address - Street 1:20505 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-1229
Mailing Address - Country:US
Mailing Address - Phone:305-232-7982
Mailing Address - Fax:305-828-7651
Practice Address - Street 1:20505 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-1229
Practice Address - Country:US
Practice Address - Phone:305-232-7982
Practice Address - Fax:305-828-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty