Healthcare Provider Details

I. General information

NPI: 1891354056
Provider Name (Legal Business Name): SHAHD NAWARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR # D1-17
GAINESVILLE FL
32610-7155
US

IV. Provider business mailing address

1210 NW 106TH ST
GAINESVILLE FL
32606-8078
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5430
  • Fax:
Mailing address:
  • Phone: 330-957-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN24115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: