Healthcare Provider Details

I. General information

NPI: 1851929434
Provider Name (Legal Business Name): ITI AGARWAL, DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 HIGHWAY 90
MILTON FL
32583-1762
US

IV. Provider business mailing address

2855 MAGNOLIA AVE
PENSACOLA FL
32503-4875
US

V. Phone/Fax

Practice location:
  • Phone: 301-806-7719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ITI AGARWAL
Title or Position: PRESIDENT
Credential:
Phone: 301-806-7719