=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376890673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH FLORIDA DENTAL SURGICAL SPECIALISTS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2012
-----------------------------------------------------
Last Update Date | 02/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9600 W SAMPLE RD SUITE 504
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-340-6550
-----------------------------------------------------
Fax | 954-340-8488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9600 W SAMPLE RD SUITE 504
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-340-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY F. ELLIOT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-340-6550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN 11443
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------