Provider Demographics
NPI:1215374293
Name:PANAMERICAN DENTAL CLINIC PA & ASSOCIATES
Entity type:Organization
Organization Name:PANAMERICAN DENTAL CLINIC PA & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-855-7767
Mailing Address - Street 1:2060 SW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2548
Mailing Address - Country:US
Mailing Address - Phone:305-444-4430
Mailing Address - Fax:305-885-7767
Practice Address - Street 1:2060 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2548
Practice Address - Country:US
Practice Address - Phone:305-444-4430
Practice Address - Fax:305-885-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20998122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006330800Medicaid