Healthcare Provider Details

I. General information

NPI: 1376856609
Provider Name (Legal Business Name): FANNY ELIZABETH ROVIRA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 W BAY TO BAY BLVD
TAMPA FL
33629-6606
US

IV. Provider business mailing address

750 13TH AVE N
ST PETERSBURG FL
33701-1014
US

V. Phone/Fax

Practice location:
  • Phone: 813-837-5147
  • Fax:
Mailing address:
  • Phone: 727-687-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: