Provider Demographics
NPI:1104274471
Name:SOUTH MIAMI DENTAL SERVICE PA
Entity type:Organization
Organization Name:SOUTH MIAMI DENTAL SERVICE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMNISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:V
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-361-5493
Mailing Address - Street 1:240 CRANDON BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149
Mailing Address - Country:US
Mailing Address - Phone:305-661-5360
Mailing Address - Fax:
Practice Address - Street 1:240 CRANDON BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149
Practice Address - Country:US
Practice Address - Phone:305-361-0351
Practice Address - Fax:305-361-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18909302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization