Basic Information
| Provider Information | |||||||||
| NPI: | 1508980871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALONSO | ||||||||
| FirstName: | LIDIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW 49TH STREET | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547288080 | ||||||||
| FaxNumber: | 9545234348 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281138 | ||||||||
| FaxNumber: | 9545234348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 09/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | DN13023 | FL | N | Dental Providers | Dentist | Dental Public Health | 1223P0221X | DN13023 | FL | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 075414500 | 05 | FL | MEDICAID |