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Provider Information for 1023219771

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1023219771

Calendar   Last Updated:  2011-11-02
  Certification Date: 


Name Value
NPI 1023219771
Enumeration Date 2007-05-30
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 6165 NW 99TH WAY
PARKLAND, FL 33076-2573
United States

Phone: 305-519-6037 | Fax:
View Map External Link
Primary Practice Address 2123 N UNIVERSITY DR
CORAL SPRINGS, FL 33071-6134
United States

Phone: 954-752-9065 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223S0112X - Dentist Oral and Maxillofacial Surgery FL DN16491