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
1	1223D0001X	Public Health Dentistry
2	1223E0200X	Endodontics
3	1223P0221X	Pediatric Dentistry
4	1223P0300X	Periodontics
5	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548410947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA SOUTHEASTERN UNIVERSITY, INC

Provider Business Mailing Address
First Line	:	3200 S UNIVERSITY DR
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	:	830 E OAKLAND PARK BLVD
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33334-2761
Country	:	US
Telephone Number	:	954-262-7530
Fax Number	:	954-568-7749

Authorized Official
Title or Position	:	CEO CLINICAL OPERATIONS
Name	:	ROBERT S OLLER
Credential	:	D.O.
Telephone Number	:	954-262-4343

Provider Enumeration Date	:	09/23/2008
Last Update Date	:	06/24/2011

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Directions to “NOVA SOUTHEASTERN UNIVERSITY, INC ” Practice Location

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