Healthcare Provider Details

I. General information

NPI: 1710921036
Provider Name (Legal Business Name): SCLAR ORAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 S RED RD SUITE 101
SOUTH MIAMI FL
33143-5428
US

IV. Provider business mailing address

7600 S RED RD SUITE 101
SOUTH MIAMI FL
33143-5428
US

V. Phone/Fax

Practice location:
  • Phone: 305-661-5297
  • Fax: 305-667-3503
Mailing address:
  • Phone: 305-661-5297
  • Fax: 305-667-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN8052
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN0010151
License Number StateFL

VIII. Authorized Official

Name: RANDENA LEONARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-661-5297