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General NPI Number Information
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NPI Number | 1861748402
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Entity Type | Organization
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Legal Business Name | BROWARD COUNTY DENTAL SURGERY PA
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Dates
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Enumeration Date | 08/01/2012
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Last Update Date | 12/17/2012
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Provider Practice Location Address
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Address Line | 5181 NE 19 AVE
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City | FT LAUDERDALE
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State | FL
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Zip | 33308
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Country | US
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Telephone | 954-562-9610
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Fax | 954-772-2569
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Provider Business Mailing Address
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Address Line | PO BOX 11223
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City | FT LAUDERDALE
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State | FL
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Zip | 33339
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Country | US
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Telephone | 954-562-9610
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Fax | 954-772-2569
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Authorized Official
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Title or Position | PRESIDENT BROWARD COUNTY DENTAL SUR
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Name | DR. JOHN R CLARKE
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Credential | DMD
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Telephone | 954-562-9610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN5272
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License Number State | FL
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