Provider Demographics
NPI:1104586973
Name:DYNAMIC ANTI-AGING MD CORP
Entity type:Organization
Organization Name:DYNAMIC ANTI-AGING MD CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KONSTANTINOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPADOPPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-803-8843
Mailing Address - Street 1:217 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131-1901
Mailing Address - Country:US
Mailing Address - Phone:786-803-8843
Mailing Address - Fax:786-803-8876
Practice Address - Street 1:217 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-1901
Practice Address - Country:US
Practice Address - Phone:786-803-8843
Practice Address - Fax:786-803-8876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date: