Provider Demographics
NPI:1902935570
Name:BELLLO-BURGOS, D.M.D. , P.A.
Entity Type:Organization
Organization Name:BELLLO-BURGOS, D.M.D. , P.A.
Other - Org Name:DORAL PARK DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BELLO-BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, DDS
Authorized Official - Phone:305-477-5299
Mailing Address - Street 1:12095 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33182-1343
Mailing Address - Country:US
Mailing Address - Phone:395-477-5299
Mailing Address - Fax:305-477-5219
Practice Address - Street 1:9757 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2381
Practice Address - Country:US
Practice Address - Phone:305-477-5299
Practice Address - Fax:305-477-5219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56761Medicaid