Provider Demographics
NPI:1366910333
Name:COSMIC SMILES PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:COSMIC SMILES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-246-4777
Mailing Address - Street 1:200 LESLIE DR APT 812
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7317
Mailing Address - Country:US
Mailing Address - Phone:646-409-6540
Mailing Address - Fax:954-246-4577
Practice Address - Street 1:3027 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3330
Practice Address - Country:US
Practice Address - Phone:646-409-6540
Practice Address - Fax:954-246-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03716034Medicaid