MEDICARE: NOVA SOUTHEASTERN UNIVERSITY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1013208800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA SOUTHEASTERN UNIVERSITY, INC

Provider Business Mailing Address
First Line	:	3200 S. UNIVERSITY DRIVE
Second Line	:	SANFORD L. ZIFF BLDG. 3RD FLOOR ROOM 4364-D
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33328-2018
Country	:	US
Telephone Number	:	954-262-4343
Fax Number	:	954-262-2269

Provider Business Practice Location Address
First Line	:	1050 NE 125TH STREET
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33161-5805
Country	:	US
Telephone Number	:	305-891-8850
Fax Number	:	305-891-3361

Authorized Official
Title or Position	:	CEO CLINICAL OPERATIONS
Name	:	ROBERT S OLLER
Credential	:	D.O.
Telephone Number	:	954-262-4399

Provider Enumeration Date	:	04/27/2011
Last Update Date	:	06/17/2011

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