MEDICARE: ANASTASIA AVINA D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN19505	FL
2	1223G0001X	General Practice Dentistry	DN63067	CA

General Provider Information

NPI Number	:	1164705679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANASTASIA AVINA D.D.S

Provider Business Mailing Address
First Line	:	12395 EL CAMINO REAL STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-3083
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 W BUSCH BLVD
Second Line	:	105
City	:	TAMPA
State	:	FL
Zip	:	33612-7707
Country	:	US
Telephone Number	:	813-931-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	02/20/2020

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