Healthcare Provider Details

I. General information

NPI: 1811349483
Provider Name (Legal Business Name): ABDALLA ASI DDS, DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653-1 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

653-1 W 8TH ST
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-2000
  • Fax:
Mailing address:
  • Phone: 904-244-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN28133
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.024873
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN46884
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: