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General NPI Number Information
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NPI Number | 1356274542
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Entity Type | Organization
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Legal Business Name | REZA ARDALAN DMD PA
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Dates
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Enumeration Date | 06/05/2026
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Last Update Date | 06/05/2026
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Provider Practice Location Address
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Address Line | 130 SW CHAMBER CT
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34986-3496
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Country | US
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Telephone | 772-344-4664
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Fax | 772-621-4498
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Provider Business Mailing Address
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Address Line | 130 SW CHAMBER CT
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34986-3496
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Country | US
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Telephone | 772-344-4664
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Fax | 772-621-4498
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Authorized Official
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Title or Position | CFO
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Name | KIMBERLY M ARDALAN
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Credential |
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Telephone | 772-344-4664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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