Healthcare Provider Details

I. General information

NPI: 1659527042
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE WEST WING 3RD FLOOR
FT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

3200 S UNIVERSITY DRIVE SANFORD L. ZIFF BLDG. 3RD FLOOR, ROOM 4364-D
FT. LAUDERDALE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-5703
  • Fax: 954-355-5490
Mailing address:
  • Phone: 954-262-4343
  • Fax: 954-262-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: ROSEMERY ESTEVEZ
Title or Position: DIR CONTRACTING AND CREDENTIALING
Credential:
Phone: 954-262-4343