Provider Demographics
NPI:1265709554
Name:UNIVERSAL DENTAL GROUP
Entity type:Organization
Organization Name:UNIVERSAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:305-903-1161
Mailing Address - Street 1:1935 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7504
Mailing Address - Country:US
Mailing Address - Phone:305-821-3344
Mailing Address - Fax:305-821-3311
Practice Address - Street 1:1935 WEST 60 STREET
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-821-3344
Practice Address - Fax:305-821-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty