Provider Demographics
NPI:1861762411
Name:WINTER GARDEN SMILES, PL
Entity type:Organization
Organization Name:WINTER GARDEN SMILES, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISSETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-694-8144
Mailing Address - Street 1:1291 WINTER GARDEN VINELAND RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-6705
Mailing Address - Country:US
Mailing Address - Phone:407-614-5955
Mailing Address - Fax:407-614-5001
Practice Address - Street 1:1291 WINTER GARDEN VINELAND RD
Practice Address - Street 2:SUITE 140
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-6705
Practice Address - Country:US
Practice Address - Phone:407-614-5955
Practice Address - Fax:407-614-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17413261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental