Basic Information
| Provider Information | |||||||||
| NPI: | 1437245529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS DIAGNOSTIC & TREATMENT CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW 49TH ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547288080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547288080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON RANDAZZO | ||||||||
| AuthorizedOfficialFirstName: | ANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9547281060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 34478 | 01 | FL | BCBS | OTHER | 061258800 | 05 | FL | MEDICAID |