Provider Demographics
NPI:1730906124
Name:PRIME PEDIATRIC DENTAL GROUP PA
Entity type:Organization
Organization Name:PRIME PEDIATRIC DENTAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLADO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-321-3790
Mailing Address - Street 1:4410 W 16TH AVE STE 52
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4410 W 16TH AVE STE 52
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7193
Practice Address - Country:US
Practice Address - Phone:305-251-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME PEDIATRIC DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-25
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty