Healthcare Provider Details

I. General information

NPI: 1700041324
Provider Name (Legal Business Name): ALI A. VAZIRI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 US HIGHWAY 441 STE C1B
LEESBURG FL
34788-7206
US

IV. Provider business mailing address

10601 U.S. HWY 441
LEESBURG FL
34788
US

V. Phone/Fax

Practice location:
  • Phone: 352-365-6442
  • Fax: 352-365-8332
Mailing address:
  • Phone: 352-365-6442
  • Fax: 352-365-8332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN14389
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: