Provider Demographics
NPI:1588361505
Name:LIFE SMILE DENTAL GROUP, INC.
Entity type:Organization
Organization Name:LIFE SMILE DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:E
Authorized Official - Last Name:NAVARRETE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-558-6832
Mailing Address - Street 1:2438 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4400
Mailing Address - Country:US
Mailing Address - Phone:305-558-6832
Mailing Address - Fax:305-558-1159
Practice Address - Street 1:2438 W 60TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-4400
Practice Address - Country:US
Practice Address - Phone:305-558-6832
Practice Address - Fax:305-558-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty