Provider Demographics
NPI:1205322856
Name:FRAGA, SALOME (DMD)
Entity type:Individual
Prefix:DR
First Name:SALOME
Middle Name:
Last Name:FRAGA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15853 SW 43 STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185
Mailing Address - Country:US
Mailing Address - Phone:305-223-9753
Mailing Address - Fax:
Practice Address - Street 1:9971 W FLAGLER STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174
Practice Address - Country:US
Practice Address - Phone:786-417-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234391223G0001X
FLDN234391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1011897600Medicaid