Provider Demographics
NPI:1215296298
Name:LITTLE SMILES DENTAL OFFICE # 3
Entity type:Organization
Organization Name:LITTLE SMILES DENTAL OFFICE # 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAYARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:CORTES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-698-7566
Mailing Address - Street 1:3469 W BOYNTON BEACH BLVD
Mailing Address - Street 2:SUITE NUMBER 20
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4611
Mailing Address - Country:US
Mailing Address - Phone:561-736-8755
Mailing Address - Fax:561-736-3996
Practice Address - Street 1:3469 W BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE NUMBER 20
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4611
Practice Address - Country:US
Practice Address - Phone:561-736-8755
Practice Address - Fax:561-736-3996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE SMILE DENTAL OFFICE #1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15894261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075542702Medicaid