Healthcare Provider Details

I. General information

NPI: 1972384873
Provider Name (Legal Business Name): OBAI TAKIEDDIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 S US HIGHWAY 441
LADY LAKE FL
32159-5237
US

IV. Provider business mailing address

331 HILLSIDE PARK ST APT 6211
MINNEOLA FL
34715-6167
US

V. Phone/Fax

Practice location:
  • Phone: 352-268-1387
  • Fax:
Mailing address:
  • Phone: 678-322-0755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN31926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: