Provider Demographics
NPI:1699446633
Name:KEY WEST DENTAL MANAGEMENT GROUP LLC
Entity type:Organization
Organization Name:KEY WEST DENTAL MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O
Authorized Official - Prefix:MRS
Authorized Official - First Name:ISIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-226-7474
Mailing Address - Street 1:1215 SIMONTON ST
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3158
Mailing Address - Country:US
Mailing Address - Phone:305-296-8541
Mailing Address - Fax:
Practice Address - Street 1:1215 SIMONTON ST
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3158
Practice Address - Country:US
Practice Address - Phone:305-296-8541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024079200Medicaid