Provider Demographics
NPI:1861748402
Name:BROWARD COUNTY DENTAL SURGERY PA
Entity type:Organization
Organization Name:BROWARD COUNTY DENTAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT BROWARD COUNTY DENTAL SUR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-562-9610
Mailing Address - Street 1:PO BOX 11223
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339
Mailing Address - Country:US
Mailing Address - Phone:954-562-9610
Mailing Address - Fax:954-772-2569
Practice Address - Street 1:5181 NE 19 AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-562-9610
Practice Address - Fax:954-772-2569
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROWARD COUNTY DENTAL SURGERY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-01
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN52721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070653100Medicaid