Healthcare Provider Details

I. General information

NPI: 1427649755
Provider Name (Legal Business Name): ROZ AGHAALIANDASTJERDI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 BELLE TERRE PKWY
PALM COAST FL
32137-8696
US

IV. Provider business mailing address

12341 NW 26TH ST
PLANTATION FL
33323-1773
US

V. Phone/Fax

Practice location:
  • Phone: 386-864-8313
  • Fax:
Mailing address:
  • Phone: 954-218-9052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36784
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN25014
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: