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General NPI Number Information
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NPI Number | 1003345802
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Entity Type | Organization
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Legal Business Name | KEYVAN TAVAKOLI, DDS, MDS, P.A.
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Dates
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Enumeration Date | 06/06/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 18964 N DALE MABRY HWY STE 103
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City | LUTZ
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State | FL
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Zip | 33548-4913
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Country | US
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Telephone | 813-591-1568
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Fax |
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Provider Business Mailing Address
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Address Line | 18964 N DALE MABRY HWY STE 103
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City | LUTZ
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State | FL
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Zip | 33548-4913
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Country | US
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Telephone | 813-591-1568
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEYVAN TAVAKOLI
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Credential | DDS
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Telephone | 910-922-5707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN22487
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License Number State | FL
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