MEDICARE: AMERICAN ORAL SURGERY INC.

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
1	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184262719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN ORAL SURGERY INC.

Provider Business Mailing Address
First Line	:	18501 PINES BLVD STE 211
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1420
Country	:	US
Telephone Number	:	954-417-1330
Fax Number	:	954-637-1955

Provider Business Practice Location Address
First Line	:	18501 PINES BLVD STE 211
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1420
Country	:	US
Telephone Number	:	954-417-1330
Fax Number	:	954-637-1955

Authorized Official
Title or Position	:	DENTIST OWNER
Name	:	WILLIAM PENA
Credential	:	DMD
Telephone Number	:	954-417-1330

Provider Enumeration Date	:	12/13/2019
Last Update Date	:	12/13/2019

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