| Entity Name: | DENTILIFE FOUR, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 14 Aug 2020 (4 years ago) |
| Document Number: | P20000061897 |
| FEI/EIN Number | 85-2594416 |
| Address: | 5473 N STATE ROAD 7, TAMARAC, FL, 33319, US |
| Mail Address: | 5473 N STATE ROAD 7, TAMARAC, FL, 33319, US |
| ZIP code: | 33319 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891309514 | 2020-09-01 | 2020-09-01 | 5473 N STATE ROAD 7, FORT LAUDERDALE, FL, 333192954, US | 5473 N STATE ROAD 7, FORT LAUDERDALE, FL, 333192954, US | |||||||||||||||||||
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| Phone | +1 954-486-7025 |
Authorized person
| Name | CINTHYA FERRADAZ |
| Role | CREDENTIALING |
| Phone | 7868991436 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 003823700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CALDERON ERIK O | Agent | 5473 N STATE ROAD 7, TAMARAC, FL, 33319 |
| Name | Role | Address |
|---|---|---|
| CALDERON ERIK O | President | 5473 N STATE ROAD 7, TAMARAC, FL, 33319 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2021-03-27 | CALDERON, ERIK O | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-03-27 | 5473 N STATE ROAD 7, TAMARAC, FL 33319 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-29 |
| ANNUAL REPORT | 2023-04-26 |
| ANNUAL REPORT | 2022-03-17 |
| ANNUAL REPORT | 2021-03-27 |
| Domestic Profit | 2020-08-14 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
