Provider Demographics
NPI:1770614794
Name:FONSECA, LUIS HERIBERTO (DMD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:HERIBERTO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12260 SW 8TH ST
Mailing Address - Street 2:SUITE 226
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-1551
Mailing Address - Country:US
Mailing Address - Phone:305-553-0666
Mailing Address - Fax:305-553-0933
Practice Address - Street 1:12260 SW 8TH ST
Practice Address - Street 2:SUITE 226
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1551
Practice Address - Country:US
Practice Address - Phone:305-553-0666
Practice Address - Fax:305-553-0933
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL88701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice