Healthcare Provider Details

I. General information

NPI: 1083082713
Provider Name (Legal Business Name): THE CENTER FOR JAW SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 SHERIDAN ST STE B
HOLLYWOOD FL
33021-3552
US

IV. Provider business mailing address

4420 SHERIDAN ST STE B
HOLLYWOOD FL
33021-3552
US

V. Phone/Fax

Practice location:
  • Phone: 954-981-4896
  • Fax:
Mailing address:
  • Phone: 954-981-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12214
License Number StateFL

VIII. Authorized Official

Name: DR. IRA E STONE
Title or Position: OWNER
Credential:
Phone: 954-981-4896