Healthcare Provider Details

I. General information

NPI: 1295150845
Provider Name (Legal Business Name): FLORIDA CENTER FOR ORAL SURGERY & DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12651 W SUNRISE BLVD SUITE 304
SUNRISE FL
33323-0906
US

IV. Provider business mailing address

12651 W SUNRISE BLVD SUITE 304
SUNRISE FL
33323-0906
US

V. Phone/Fax

Practice location:
  • Phone: 954-845-0098
  • Fax: 954-845-0280
Mailing address:
  • Phone: 954-845-0098
  • Fax: 954-845-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16488
License Number StateFL

VIII. Authorized Official

Name: DR. DAMONE E SMITH
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 954-845-0098