MEDICARE: LAS OLAS DENTAL ORTHODONTIC AND IMPLANT CENTER

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1033768742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS OLAS DENTAL ORTHODONTIC AND IMPLANT CENTER

Provider Business Mailing Address
First Line	:	800 E BROWARD BLVD STE 305
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E BROWARD BLVD STE 305
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2024
Country	:	US
Telephone Number	:	954-859-1199
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DENNIS SOLOMON SEVEL
Credential	:
Telephone Number	:	954-599-6835

Provider Enumeration Date	:	09/05/2019
Last Update Date	:	09/05/2019

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