Healthcare Provider Details

I. General information

NPI: 1013219922
Provider Name (Legal Business Name): SHIVA KHATAMI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

110 N FEDERAL HWY APT # 813
FT LAUDERDALE FL
33301-1180
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-7500
  • Fax: 954-262-7164
Mailing address:
  • Phone: 954-632-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDTP533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: