Provider Demographics
NPI:1427263995
Name:LASTRA, IDALIA (DMD)
Entity type:Individual
Prefix:
First Name:IDALIA
Middle Name:
Last Name:LASTRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2498 S.W. 3 AVE.
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129
Mailing Address - Country:US
Mailing Address - Phone:305-856-7180
Mailing Address - Fax:
Practice Address - Street 1:2498 S.W. 3 AVE.
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129
Practice Address - Country:US
Practice Address - Phone:305-856-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 77861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics