MEDICARE: DR. OMID KHEZRI DDS

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	122300000X	Dentist	DN22027	FL

General Provider Information

NPI Number	:	1518319250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMID KHEZRI DDS

Provider Business Mailing Address
First Line	:	272 E GRAVES AVE
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-5269
Country	:	US
Telephone Number	:	386-775-4300
Fax Number	:	386-775-0630

Provider Business Practice Location Address
First Line	:	3135 COLUMBIA BLVD STE 101
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-7833
Country	:	US
Telephone Number	:	321-567-2000
Fax Number	:	321-567-2070

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

Provider Enumeration Date	:	07/06/2016
Last Update Date	:	01/08/2026

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