=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164998308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLERMONT KIDS DENTISTRY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2018
-----------------------------------------------------
Last Update Date | 10/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1655 E HWY 50 STE 101
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-446-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 HARLEY CT
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765-8359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-446-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FARAZ TARTIBI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 407-446-6644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------