Healthcare Provider Details

I. General information

NPI: 1629812557
Provider Name (Legal Business Name): AZIMAIE DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MAIN ST
GAITHERSBURG MD
20878-6574
US

IV. Provider business mailing address

308 MAIN ST
GAITHERSBURG MD
20878-6574
US

V. Phone/Fax

Practice location:
  • Phone: 301-747-0575
  • Fax:
Mailing address:
  • Phone: 301-747-0575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. TAHA AZIMAIE
Title or Position: PRESIDENT/OWNER
Credential: M.S. D.M.D. M.S.E.
Phone: 301-747-0575