Healthcare Provider Details

I. General information

NPI: 1548410947
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 E OAKLAND PARK BLVD
OAKLAND PARK FL
33334-2761
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 954-262-7530
  • Fax: 954-568-7749
Mailing address:
  • Phone: 954-262-4343
  • Fax: 954-262-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ROBERT S OLLER
Title or Position: CEO CLINICAL OPERATIONS
Credential: D.O.
Phone: 954-262-4343