Provider Demographics
NPI:1073002259
Name:1500 DENTAL LLC
Entity Type:Organization
Organization Name:1500 DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE & CREDENTIALING COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:NEKELDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, DPMA
Authorized Official - Phone:954-715-1000
Mailing Address - Street 1:1500 N FEDERAL HWY STE 250
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-5603
Mailing Address - Country:US
Mailing Address - Phone:954-715-1000
Mailing Address - Fax:954-372-1000
Practice Address - Street 1:1500 N FEDERAL HWY STE 250
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-5603
Practice Address - Country:US
Practice Address - Phone:954-715-1000
Practice Address - Fax:954-372-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14284122300000X
FLDN163361223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1407978679OtherNPI
FL1043392111OtherNPI