MEDICARE: DR. NEDA AZADIVATAN-LE 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	1223P0300X	Periodontics	049227	NY
2	1223P0300X	Periodontics	10387	SC

General Provider Information

NPI Number	:	1922121177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEDA AZADIVATAN-LE D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 15639
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29587-5639
Country	:	US
Telephone Number	:	843-650-7171
Fax Number	:	843-650-7173

Provider Business Practice Location Address
First Line	:	1947 GLENNS BAY RD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-4833
Country	:	US
Telephone Number	:	843-650-7171
Fax Number	:	843-650-7173

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	02/13/2024

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