Healthcare Provider Details

I. General information

NPI: 1255804860
Provider Name (Legal Business Name): PLANTATION ORAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 NW 5TH ST STE 105
PLANTATION FL
33317-1612
US

IV. Provider business mailing address

7500 NW 5TH ST STE 105
PLANTATION FL
33317-1612
US

V. Phone/Fax

Practice location:
  • Phone: 954-792-5544
  • Fax: 954-587-6442
Mailing address:
  • Phone: 954-792-5544
  • Fax: 954-587-6442

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: JOEL A BERLEY
Title or Position: OWNER
Credential:
Phone: 954-792-5544