MEDICARE: DR. YEGANEH REZAIE D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN19415	FL

General Provider Information

NPI Number	:	1043506041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YEGANEH REZAIE D.M.D

Provider Business Mailing Address
First Line	:	3801 HOLLYWOOD BLVD
Second Line	:	SUITE 225
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6758
Country	:	US
Telephone Number	:	614-906-0115
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 HOLLYWOOD BLVD
Second Line	:	SUITE 225
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6758
Country	:	US
Telephone Number	:	614-906-0115
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2011
Last Update Date	:	08/10/2014

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