Provider Demographics
NPI:1902636160
Name:BANEGA, ELISSABET
Entity type:Individual
Prefix:
First Name:ELISSABET
Middle Name:
Last Name:BANEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 NW 20TH ST BLDG G10
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-4618
Mailing Address - Country:US
Mailing Address - Phone:305-363-2222
Mailing Address - Fax:
Practice Address - Street 1:750 NW 20TH ST BLDG G10
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-4618
Practice Address - Country:US
Practice Address - Phone:305-363-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418868122300000X
FLDN29448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist