Provider Demographics
NPI:1447656491
Name:TOTAL DENTAL CARE OF FLORIDA, LLC
Entity type:Organization
Organization Name:TOTAL DENTAL CARE OF FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-747-7711
Mailing Address - Street 1:PO BOX 440308
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-0308
Mailing Address - Country:US
Mailing Address - Phone:786-971-2319
Mailing Address - Fax:
Practice Address - Street 1:4410 W 16TH AVE STE 30
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7835
Practice Address - Country:US
Practice Address - Phone:305-747-7711
Practice Address - Fax:305-697-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002973600Medicaid