Provider Demographics
NPI:1689195828
Name:SMILE PERFECT DENTAL HEALTH II
Entity type:Organization
Organization Name:SMILE PERFECT DENTAL HEALTH II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-6712
Mailing Address - Street 1:580 E 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1962
Mailing Address - Country:US
Mailing Address - Phone:305-557-6712
Mailing Address - Fax:
Practice Address - Street 1:1075 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4103
Practice Address - Country:US
Practice Address - Phone:305-557-6712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN133551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002781000Medicaid