Provider Demographics
NPI:1487413571
Name:AGAMA CUEVA, ANDRE SEBASTIAN
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:SEBASTIAN
Last Name:AGAMA CUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15090 BOOK CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-1766
Mailing Address - Country:US
Mailing Address - Phone:321-347-7260
Mailing Address - Fax:
Practice Address - Street 1:750 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3817
Practice Address - Country:US
Practice Address - Phone:321-347-7260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist