Healthcare Provider Details

I. General information

NPI: 1851473870
Provider Name (Legal Business Name): SOUTH FLORIDA ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MILITARY TRL #110
JUPITER FL
33458-7040
US

IV. Provider business mailing address

1025 MILITARY TRL #110
JUPITER FL
33458-7040
US

V. Phone/Fax

Practice location:
  • Phone: 561-743-8311
  • Fax: 561-744-6201
Mailing address:
  • Phone: 561-743-8311
  • Fax: 561-744-6201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THERESA STRAUSS
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 406-756-2415