Provider Demographics
NPI:1912318320
Name:PEDIATRIC DENTISTRY OF MIAMI PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF MIAMI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-598-3384
Mailing Address - Street 1:9485 SW 72 STREET
Mailing Address - Street 2:SUITE A240
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173
Mailing Address - Country:US
Mailing Address - Phone:786-360-5401
Mailing Address - Fax:
Practice Address - Street 1:9485 SW 72ND ST
Practice Address - Street 2:SUITE A240
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3242
Practice Address - Country:US
Practice Address - Phone:786-360-5401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN184281223P0221X
FLDN177371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty