| Entity Name: | THE GREEN DENTAL STUDIO, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 05 Jan 2022 (3 years ago) |
| Document Number: | P22000000618 |
| FEI/EIN Number | 87-4303819 |
| Address: | 1330 SE 4TH AVE STE L, FT LAUDERDALE, FL 33316 |
| Mail Address: | 1330 SE 4TH AVE STE L, FT LAUDERDALE, FL 33316 |
| ZIP code: | 33316 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1134825052 | 2023-02-02 | 2023-02-02 | 1330 SE 4TH AVE STE L, FORT LAUDERDALE, FL, 333161958, US | 1330 SE 4TH AVE STE L, FORT LAUDERDALE, FL, 333161958, US | |||||||||||||||||||
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| Phone | +1 954-990-8389 |
Authorized person
| Name | DR. JOSE ANTONIO ALFONSO |
| Role | OWNER |
| Phone | 7866148927 |
Taxonomy
| Taxonomy Code | 261QD0000X - Dental Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1760008486 |
| State | NJ |
| Name | Role | Address |
|---|---|---|
| STESZEWSKI, JONATHAN, ESQ | Agent | 15100 NW 67 AVE STE 200, MIAMI LAKES, FL 33014 |
| Name | Role | Address |
|---|---|---|
| GUERRA ECHEVARRIA, ARLEIDYS, DR | President | 1330 SE 4TH AVE STE L, FT LAUDERDALE, FL 33316 |
| Name | Role | Address |
|---|---|---|
| ALFONSO RODRIGUEZ, JOSE ANTONIO, DR | Vice President | 1330 SE 4TH AVE STE L, FT LAUDERDALE, FL 33316 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-21 |
| ANNUAL REPORT | 2023-04-27 |
| Domestic Profit | 2022-01-05 |
Date of last update: 13 Jan 2025
Sources: Florida Department of State
