Provider Demographics
NPI:1063534063
Name:BRAVO, MARTA (DDS)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9210 SW 67TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2344
Mailing Address - Country:US
Mailing Address - Phone:305-275-0033
Mailing Address - Fax:
Practice Address - Street 1:6507 CORAL WAY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1843
Practice Address - Country:US
Practice Address - Phone:305-266-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00132521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3576OtherCOMP BENEFITS
FL632776OtherUNITED CONCORDIA
FL69649OtherBLUE CROSS BLUE SHIELD