MEDICARE: NOVA DENTAL 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	DN15793	FL

General Provider Information

NPI Number	:	1730535345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA DENTAL INC

Provider Business Mailing Address
First Line	:	1501 SE 23RD AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-7507
Country	:	US
Telephone Number	:	954-825-9128
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 SE 23RD AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-7507
Country	:	US
Telephone Number	:	954-825-9128
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SANTIAGO ROLDAN
Credential	:	DMD
Telephone Number	:	954-825-9128

Provider Enumeration Date	:	05/12/2016
Last Update Date	:	05/12/2016

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