Healthcare Provider Details

I. General information

NPI: 1598620197
Provider Name (Legal Business Name): HERITAGE HARBOUR DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 SR 64 E, UNIT 102
BRADENTON FL
34212
US

IV. Provider business mailing address

PO BOX 660041
DALLAS TX
75266-0041
US

V. Phone/Fax

Practice location:
  • Phone: 941-277-4698
  • Fax: 941-213-0822
Mailing address:
  • Phone: 714-845-8890
  • Fax: 303-952-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY A AZADI
Title or Position: OWNER
Credential: DDS
Phone: 941-277-4698