Healthcare Provider Details

I. General information

NPI: 1215628110
Provider Name (Legal Business Name): FIRDAVS Z ABZHABAROV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12628 FREMONT AVE
ZIMMERMAN MN
55398-9735
US

IV. Provider business mailing address

209 5TH ST SE APT 203
MINNEAPOLIS MN
55414-1141
US

V. Phone/Fax

Practice location:
  • Phone: 763-317-1166
  • Fax:
Mailing address:
  • Phone: 612-360-3964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14875
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: