Provider Demographics
NPI:1053762898
Name:EAST COAST FAMILY DENTAL LAUDERDALE PA
Entity type:Organization
Organization Name:EAST COAST FAMILY DENTAL LAUDERDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-264-0747
Mailing Address - Street 1:6741 SW 24TH ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1762
Mailing Address - Country:US
Mailing Address - Phone:305-264-0747
Mailing Address - Fax:305-264-0595
Practice Address - Street 1:4358 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-5208
Practice Address - Country:US
Practice Address - Phone:954-776-3320
Practice Address - Fax:954-776-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN111501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty