Provider Demographics
NPI:1982077939
Name:FORTUNE SMILES INC
Entity Type:Organization
Organization Name:FORTUNE SMILES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MADELENE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-259-9120
Mailing Address - Street 1:2879 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1440
Mailing Address - Country:US
Mailing Address - Phone:954-474-2499
Mailing Address - Fax:954-474-1966
Practice Address - Street 1:2879 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-1440
Practice Address - Country:US
Practice Address - Phone:954-474-2499
Practice Address - Fax:954-474-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD18770122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013776Medicaid