MEDICARE: DR. PAVEL IVANOV IVANOV D.M.D.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN19160	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790020824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAVEL IVANOV IVANOV D.M.D.

Provider Business Mailing Address
First Line	:	12866 BISCAYNE BLVD
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12866 BISCAYNE BLVD
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2007
Country	:	US
Telephone Number	:	786-540-1919
Fax Number	:

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

Provider Enumeration Date	:	11/29/2012
Last Update Date	:	01/02/2020

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