Provider Demographics
NPI:1669763462
Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Entity type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROBER
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-262-4343
Mailing Address - Street 1:3200 S. UNIVERSITY DRIVE
Mailing Address - Street 2:SANFORD L. ZIFF BLDG. 3RD FLOOR ROOM 4364-D
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-4343
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:3075 NW 35TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1107
Practice Address - Country:US
Practice Address - Phone:954-739-6233
Practice Address - Fax:954-733-9579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVA SOUTHEASTERN UNIVERSITY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-27
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty