=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407689078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ARIANNA LUIZA KHAIRA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2024
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 528 W BALDWIN RD UNIT B
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-0128
-----------------------------------------------------
Fax | 850-481-1976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 PENNY ROYAL ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-219-6653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 29509
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------