Healthcare Provider Details

I. General information

NPI: 1922250703
Provider Name (Legal Business Name): FORT LAUDERDALE DMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S. ANDREWS AVENUE
FORT LAUDERDALE FL
33316
US

IV. Provider business mailing address

2000 S. ANDREWS AVENUE
FORT LAUDERDALE FL
33316
US

V. Phone/Fax

Practice location:
  • Phone: 954-356-9956
  • Fax: 954-356-8120
Mailing address:
  • Phone: 954-356-9956
  • Fax: 954-356-8120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16358
License Number StateFL

VIII. Authorized Official

Name: DR. ROLAND ANTHONY HERNANDEZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 954-356-9956