Healthcare Provider Details

I. General information

NPI: 1093967911
Provider Name (Legal Business Name): ELLIE SUZUKI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-1805
  • Fax: 954-262-1782
Mailing address:
  • Phone: 954-262-1805
  • Fax: 954-262-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDTP508
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401412211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: