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General NPI Number Information
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NPI Number | 1073002259
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Entity Type | Organization
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Legal Business Name | 1500 DENTAL LLC
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Dates
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Enumeration Date | 05/03/2018
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Last Update Date | 05/03/2018
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Provider Practice Location Address
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Address Line | 1500 N FEDERAL HWY STE 250
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-5603
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Country | US
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Telephone | 954-715-1000
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Fax | 954-372-1000
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Provider Business Mailing Address
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Address Line | 1500 N FEDERAL HWY STE 250
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-5603
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Country | US
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Telephone | 954-715-1000
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Fax | 954-372-1000
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Authorized Official
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Title or Position | INSURANCE & CREDENTIALING COORDINAT
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Name | NEKELDA A WEISS
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Credential | CDA, DPMA
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Telephone | 954-715-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN14284
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN16336
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License Number State | FL
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