Healthcare Provider Details

I. General information

NPI: 1235628991
Provider Name (Legal Business Name): MICHAEL JONATHAN THEISS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17901 NW 5TH STREET SUITE # 101
PEMBROKE PINES FL
33029
US

IV. Provider business mailing address

790 E BROWARD BLVD UNIT 2403
FORT LAUDERDALE FL
33301
US

V. Phone/Fax

Practice location:
  • Phone: 954-437-2222
  • Fax: 954-437-2244
Mailing address:
  • Phone: 516-359-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0442000331
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0442000331
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN26758
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: