Healthcare Provider Details

I. General information

NPI: 1841344926
Provider Name (Legal Business Name): SUNDARALINGAM PREMARAJ BDS, MS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SOUTH UNIVERSITY DRIVE NOVA SOUTHEASTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
FORT LAUDERDALE FL
33328
US

IV. Provider business mailing address

3200 SOUTH UNIVERSITY DRIVE NOVA SOUTHWESTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
FORT LAUDERDALE FL
33328
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-1896
  • Fax:
Mailing address:
  • Phone: 954-262-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number112
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDTP759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: