=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114310943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEPIDEH SABOOREE MD, DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2015
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960115 GATEWAY BLVD STE 1
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-9129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-491-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 BRYNFIELD PKWY
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-2985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-626-0063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 92077
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | DGD.10930
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | DN21538
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------