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General NPI Number Information
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NPI Number | 1265862593
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Entity Type | Organization
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Legal Business Name | DENTAL LAS OLAS PA
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Dates
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Enumeration Date | 11/22/2013
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Last Update Date | 11/22/2013
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Provider Practice Location Address
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Address Line | 401 E LAS OLAS BLVD SUITE #140
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City | FORT LAUDERDALE
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State | FL
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Zip | 33301-2210
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Country | US
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Telephone | 954-524-6595
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Fax |
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Provider Business Mailing Address
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Address Line | 900 NE 12TH AVE APT 602
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City | HALLANDALE BEACH
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State | FL
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Zip | 33009-2655
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Country | US
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Telephone | 617-818-4596
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. NADEZDA SELMIC
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Credential | DMD
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Telephone | 617-818-4596
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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 | 20436
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License Number State | FL
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