Provider Demographics
NPI:1992187876
Name:TRAVIESAS HERRERA, ELADIO MIGUEL
Entity Type:Individual
Prefix:
First Name:ELADIO
Middle Name:MIGUEL
Last Name:TRAVIESAS HERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9231 NW 114TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4306
Mailing Address - Country:US
Mailing Address - Phone:786-458-5605
Mailing Address - Fax:
Practice Address - Street 1:4301 PALM AVE STE F
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4060
Practice Address - Country:US
Practice Address - Phone:305-826-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
FLDN22857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty