Healthcare Provider Details

I. General information

NPI: 1629637871
Provider Name (Legal Business Name): AMMAR SHANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

5116 BLANDING BLVD
JACKSONVILLE FL
32210-7840
US

IV. Provider business mailing address

5116 BLANDING BLVD
JACKSONVILLE FL
32210-7840
US

V. Phone/Fax

Practice location:
  • Phone: 904-573-7900
  • Fax: 904-903-4537
Mailing address:
  • Phone: 904-573-7900
  • Fax: 904-903-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN24222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: