Icom Sunrise LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

ICOM SUNRISE LLC

Practice address

12651 W Sunrise Blvd
Sunrise, FL 33323-0906

Phone

(954) 356-2721

Fax

(786) 221-4442

NPI assigned

Jan 3, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tatiana Santiago Herzog, DDS

Title

Dentist

Phone

(954) 356-2721

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1704240000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704240000000",
    "number": "1093585853",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 NE 13TH ST",
            "city": "FT LAUDERDALE",
            "state": "FL",
            "postal_code": "333041109",
            "telephone_number": "305-409-5392"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12651 W SUNRISE BLVD",
            "city": "SUNRISE",
            "state": "FL",
            "postal_code": "333230906",
            "telephone_number": "954-356-2721",
            "fax_number": "786-221-4442"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICOM SUNRISE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-03",
        "last_updated": "2024-01-03",
        "certification_date": "2024-01-03",
        "status": "A",
        "authorized_official_last_name": "SANTIAGO HERZOG",
        "authorized_official_first_name": "TATIANA",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "954-356-2721",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.