Basic Information
| Provider Information | |||||||||
| NPI: | 1134503428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASTELLANO | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1695 N PARK DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333263294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544510265 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1695 N PARK DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333263294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544510265 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2015 | ||||||||
| LastUpdateDate: | 08/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN 21373 | FL | N | Dental Providers | Dentist | 1223P0221X | DN21373 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.