MEDICARE: HOLLYWOOD ORTHODONTICS, 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
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1811464639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	3113 STIRLING RD STE 101
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6547
Country	:	US
Telephone Number	:	305-458-3384
Fax Number	:

Provider Business Practice Location Address
First Line	:	3113 STIRLING RD STE 101
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6547
Country	:	US
Telephone Number	:	305-458-3384
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FAUSTO NICIEZA
Credential	:	DMD
Telephone Number	:	954-985-3883

Provider Enumeration Date	:	10/30/2018
Last Update Date	:	10/30/2018

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