Provider Demographics
NPI:1972951952
Name:RGD DENTAL CORP
Entity type:Organization
Organization Name:RGD DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REYDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-536-7537
Mailing Address - Street 1:11870 HIALEAH GARDENS BLVD
Mailing Address - Street 2:SUITE 129 A
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4235
Mailing Address - Country:US
Mailing Address - Phone:786-536-7537
Mailing Address - Fax:786-534-5934
Practice Address - Street 1:11870 HIALEAH GARDENS BLVD
Practice Address - Street 2:SUITE 129 A
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4235
Practice Address - Country:US
Practice Address - Phone:786-536-7537
Practice Address - Fax:786-534-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN199231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016573500Medicaid