Provider Demographics
NPI:1528838372
Name:ICOM BAY HARBOR LLC
Entity type:Organization
Organization Name:ICOM BAY HARBOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-560-5859
Mailing Address - Street 1:611 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1109
Mailing Address - Country:US
Mailing Address - Phone:786-713-9290
Mailing Address - Fax:
Practice Address - Street 1:1160 KANE CONCOURSE STE 203
Practice Address - Street 2:
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2020
Practice Address - Country:US
Practice Address - Phone:305-560-5859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty