Healthcare Provider Details

I. General information

NPI: 1568946390
Provider Name (Legal Business Name): BAHA QABLAWI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAINT JOHNS MEDICAL PARK DR STE B
ST AUGUSTINE FL
32086-5955
US

IV. Provider business mailing address

8981 SW 17TH CT
MIRAMAR FL
33025-7600
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-3208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23960
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: