Healthcare Provider Details

I. General information

NPI: 1902918543
Provider Name (Legal Business Name): AZADEH YAVARI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3557 HENDRICKS AVE
JACKSONVILLE FL
32207-5309
US

IV. Provider business mailing address

3557 HENDRICKS AVE
JACKSONVILLE FL
32207-5309
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1023
  • Fax:
Mailing address:
  • Phone: 904-396-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19121
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: