Basic Information
| Provider Information | |||||||||
| NPI: | 1619441516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DORAL MODERN DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 N FLAMINGO RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864883009 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 N FLAMINGO RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864883009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2019 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | RIOS | ||||||||
| AuthorizedOfficialFirstName: | MILAGRITOS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7864883009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.