Basic Information
| Provider Information | |||||||||
| NPI: | 1063483444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CABASSA LATONI | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | JOAQUIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 290370 | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333290370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624346 | ||||||||
| FaxNumber: | 9542622269 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 NE 26TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | WILTON MANORS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333051239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054843657 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/25/2020 | ||||||||
| NPIReactivationDate: | 02/28/2020 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DTP695 | FL | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 102175000 | 05 | FL | MEDICAID |