Provider Demographics
NPI:1639484686
Name:GALLEGO-ECKSTEIN, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:GALLEGO-ECKSTEIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 NE 204TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2250
Mailing Address - Country:US
Mailing Address - Phone:954-682-9303
Mailing Address - Fax:
Practice Address - Street 1:3031 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4462
Practice Address - Country:US
Practice Address - Phone:305-945-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-15
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL204531223P0700X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics