Basic Information
| Provider Information | |||||||||
| NPI: | 1548406812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S UNIVERSITY DRIVE | ||||||||
| Address2: | SANFORD L. ZIFF BLDG. 3RD FLOOR, ROOM 4364-D | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624343 | ||||||||
| FaxNumber: | 9542622269 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON STREET 2ND FLOOR SUITE 200 | ||||||||
| Address2: | JOE DIMAGGIO CHILDREN'S HOSPITAL MEDICAL OFFICE CENTRE | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542622187 | ||||||||
| FaxNumber: | 9542622910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.