| Entity Name: | KEY WEST DENTAL MANAGEMENT GROUP, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 07 Sep 2021 (3 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 27 Oct 2021 (3 years ago) |
| Document Number: | L21000395642 |
| FEI/EIN Number | 87-2558842 |
| Address: | 1215 SIMONTON STREET, KEY WEST, FL 33040 |
| Mail Address: | 1215 SIMONTON STREET, KEY WEST, FL 33040 |
| ZIP code: | 33040 |
| County: | Monroe |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1699446633 | 2021-09-21 | 2021-09-21 | 1215 SIMONTON ST, KEY WEST, FL, 330403158, US | 1215 SIMONTON ST, KEY WEST, FL, 330403158, US | |||||||||||||||||||||||||||||||
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| Phone | +1 305-296-8541 |
Authorized person
| Name | MRS. ISIS SAMPEDRO |
| Role | C.O.O |
| Phone | 7862267474 |
Taxonomy
| Taxonomy Code | 1223E0200X - Endodontist |
| Is Primary | No |
| Taxonomy Code | 1223G0001X - General Practice Dentistry |
| Is Primary | No |
| Taxonomy Code | 1223S0112X - Oral and Maxillofacial Surgery (Dentist) |
| Is Primary | No |
| Taxonomy Code | 261QD0000X - Dental Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 024079200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| STESZEWSKI, JONATHAN, ESQ. | Agent | 15100 NW 67TH AVE., SUITE 200, MIAMI LAKES, FL 33014 |
| Name | Role | Address |
|---|---|---|
| SAMPEDRO, ISIS | Manager | 1215 SIMONTON STREET, KEY WEST, FL 33040 |
| Name | Role | Address |
|---|---|---|
| SANTIESTEBAN, AYMARA, DDS | Authorized Member | 1215 SIMONTON STREET, KEY WEST, FL 33040 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000129129 | BRICKELL DENTAL CARE | ACTIVE | 2024-10-21 | 2029-12-31 | No data | 65 SE 9TH STREET, MIAMI, FL, 33131 |
| G22000139538 | LOS ANGELES DENTAL CARE | ACTIVE | 2022-11-09 | 2027-12-31 | No data | 5240 GOLDEN GATE PKWY, NAPLES, FL, 34116 |
| G22000044087 | AYMARA DENTAL CARE | ACTIVE | 2022-04-07 | 2027-12-31 | No data | 1215 SIMONTON STREET, KEY WEST, FL, 33040 |
| G22000014395 | OLDTOWN DENTAL | ACTIVE | 2022-02-07 | 2027-12-31 | No data | 1215 SIMONTON ST, KEY WEST, FL, 33040 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2021-10-27 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-02-04 |
| ANNUAL REPORT | 2024-02-20 |
| ANNUAL REPORT | 2023-03-15 |
| ANNUAL REPORT | 2022-01-20 |
| LC Amendment | 2021-10-27 |
| Florida Limited Liability | 2021-09-07 |
Date of last update: 13 Feb 2025
Sources: Florida Department of State
