| Entity Name: | PEDO ORTHO DENTAL SPECIALISTS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 02 Oct 2017 (7 years ago) |
| Date of dissolution: | 24 Jun 2018 (7 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 24 Jun 2018 (7 years ago) |
| Document Number: | L17000203356 |
| Address: | 8950 S.W. 74TH COURT, SUITE 1214, MIAMI, FL, 33156, US |
| Mail Address: | 8950 S.W. 74TH COURT, SUITE 1214, MIAMI, FL, 33156, US |
| ZIP code: | 33156 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1538673975 | 2017-11-21 | 2017-11-21 | 8950 SW 74TH CT STE 124, MIAMI, FL, 331563171, US | 8950 SW 74TH CT STE 124, MIAMI, FL, 331563171, US | |||||||||||||||||||||||||||||
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| Phone | +1 954-268-9825 |
Authorized person
| Name | STEPHEN CRISCUOLO |
| Role | DMD/OWNER |
| Phone | 9542689825 |
Taxonomy
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| License Number | DN21814 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 008662900 |
| State | FL |
| Issuer | MEDICAID |
| Number | 019273100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FISHMAN LEWIS W | Agent | 7700 NORTH KENDALL DRIVE, MIAMI, FL, 33156 |
| Name | Role | Address |
|---|---|---|
| IDENTAL SYSTEMS LLC | Authorized Member | No data |
| GRUSSMARK STEPHEN | Authorized Member | 8950 S.W. 74TH COURT SUITE 1214, MIAMI, FL, 33156 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2018-06-24 | No data | No data |
| Name | Date |
|---|---|
| Florida Limited Liability | 2017-10-02 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
