Provider Demographics
NPI:1922250703
Name:FORT LAUDERDALE DMS
Entity Type:Organization
Organization Name:FORT LAUDERDALE DMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-356-9956
Mailing Address - Street 1:2000 S. ANDREWS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316
Mailing Address - Country:US
Mailing Address - Phone:954-356-9956
Mailing Address - Fax:954-356-8120
Practice Address - Street 1:2000 S. ANDREWS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-356-9956
Practice Address - Fax:954-356-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070434200Medicaid
FL070434200Medicaid
FLE1930Medicare UPIN