=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932201142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OASIS DENTAL ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10796 PINES BLVD SUITE 203
-----------------------------------------------------
City | PENBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-499-1599
-----------------------------------------------------
Fax | 954-499-5799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10796 PINES BLVD SUITE 203
-----------------------------------------------------
City | PENBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-499-1599
-----------------------------------------------------
Fax | 954-499-5799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER DENTIST
-----------------------------------------------------
Name | MR. MICHAEL ANDREW GORMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-499-1599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------