Provider Demographics
NPI:1265862593
Name:DENTAL LAS OLAS PA
Entity Type:Organization
Organization Name:DENTAL LAS OLAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NADEZDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SELMIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-818-4596
Mailing Address - Street 1:900 NE 12TH AVE
Mailing Address - Street 2:APT 602
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2655
Mailing Address - Country:US
Mailing Address - Phone:617-818-4596
Mailing Address - Fax:
Practice Address - Street 1:401 E LAS OLAS BLVD
Practice Address - Street 2:SUITE #140
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2210
Practice Address - Country:US
Practice Address - Phone:954-524-6595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty