Provider Demographics
NPI:1679905848
Name:HIREZI HIREZI DMD PA
Entity type:Organization
Organization Name:HIREZI HIREZI DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LOTTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DESCALLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-733-9191
Mailing Address - Street 1:4495 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4716
Mailing Address - Country:US
Mailing Address - Phone:904-733-9191
Mailing Address - Fax:
Practice Address - Street 1:4495 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4716
Practice Address - Country:US
Practice Address - Phone:904-733-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIREZI FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13089261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639241821OtherALL DENTAL INSURANCE
FL=========OtherDENTAL INSURANCE