Basic Information
| Provider Information | |||||||||
| NPI: | 1669763462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 3075 NW 35TH AVE | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333111107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547396233 | ||||||||
| FaxNumber: | 9547339579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.