Provider Demographics
NPI:1043505068
Name:MTA DENTAL LLC
Entity type:Organization
Organization Name:MTA DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGES ASSI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-484-7879
Mailing Address - Street 1:6268 W SAMPLE RD
Mailing Address - Street 2:UNIT 401
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3272
Mailing Address - Country:US
Mailing Address - Phone:305-484-7879
Mailing Address - Fax:
Practice Address - Street 1:6268 W SAMPLE RD
Practice Address - Street 2:UNIT 401
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-3272
Practice Address - Country:US
Practice Address - Phone:305-484-7879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN179621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty