Basic Information
| Provider Information | |||||||||
| NPI: | 1295974293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROWARD CHILDREN'S CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | ASSEMBLY BLDG # 2 ROOM 202 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624343 | ||||||||
| FaxNumber: | 9542622269 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330607543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549437638 | ||||||||
| FaxNumber: | 9549435950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO / CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTERN UNIVERSITY | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.