=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093726846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AZITA DAVANLOU DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8180 LARK BROWN ROAD SUITE #202
-----------------------------------------------------
City | ELKRIDGE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-799-7172
-----------------------------------------------------
Fax | 410-799-7132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 PFEFFERKORN ROAD
-----------------------------------------------------
City | WEST FRIENDSHIP
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-489-9860
-----------------------------------------------------
Fax | 410-489-9861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12454
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------