Healthcare Provider Details

I. General information

NPI: 1992456560
Provider Name (Legal Business Name): WEST SHERIDAN DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15641 SHERIDAN ST STE 400
DAVIE FL
33331-3485
US

IV. Provider business mailing address

15641 SHERIDAN ST STE 400
DAVIE FL
33331-3485
US

V. Phone/Fax

Practice location:
  • Phone: 754-215-4704
  • Fax: 786-497-3409
Mailing address:
  • Phone: 754-215-4704
  • Fax: 786-497-3409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS F VILLANUEVA
Title or Position: DENTIST/MANAGER
Credential: DDS, PROSTHODONTIST
Phone: 754-215-4704