| Organization Name: | MAIN STREET CHILDREN'S DENTISTRY OF MIAMI LAKES, PLLC |
| NPI Number: | 1043611858 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STEPHANIE GOMEZ (PROVIDER RELATIONS) |
| Mailing Address: | 15501 Nw 67th Ave Ste 201 Miami Lakes |
| State: | FL US |
| Postal Code: | 330142108 |
| Phone Number: | 7865774968 |
| Fax Number: | |
| NPI Enumeration Date: | 09/11/2014 |
| NPI Last Update Date: | 06/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |