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NPI Code Detail

MEDICARE: 1500 DENTAL LLC

MEDICARE: 1500 DENTAL LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistDN14284FL
21223P0300XPeriodonticsDN16336FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11407978679OTHERFLNPI
21043392111OTHERFLNPI

General Provider Information

NPI Number : 1073002259
Entity Type Code : Organization
Provider Name (Legal Business Name) : 1500 DENTAL LLC
Provider Business Mailing Address
First Line : 1500 N FEDERAL HWY STE 250
Second Line :
City : FORT LAUDERDALE
State : FL
Zip : 33304-5603
Country : US
Telephone Number : 954-715-1000
Fax Number : 954-372-1000
Provider Business Practice Location Address
First Line : 1500 N FEDERAL HWY STE 250
Second Line :
City : FORT LAUDERDALE
State : FL
Zip : 33304-5603
Country : US
Telephone Number : 954-715-1000
Fax Number : 954-372-1000
Authorized Official
Title or Position : INSURANCE & CREDENTIALING COORDINAT
Name : NEKELDA A WEISS
Credential : CDA, DPMA
Telephone Number : 954-715-1000
Provider Enumeration Date : 05/03/2018
Last Update Date : 05/03/2018

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