Provider Demographics
NPI:1679781678
Name:LASTRA, TERESA (DDS)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:LASTRA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 SW 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2662
Mailing Address - Country:US
Mailing Address - Phone:305-856-5141
Mailing Address - Fax:
Practice Address - Street 1:2150 SW 21ST AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2662
Practice Address - Country:US
Practice Address - Phone:305-856-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL96571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice