Provider Demographics
NPI:1033778436
Name:AKHAVAN, TINA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:AKHAVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SE 5TH AVE APT 714
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2968
Mailing Address - Country:US
Mailing Address - Phone:954-461-5584
Mailing Address - Fax:
Practice Address - Street 1:3333 NORTHLAKE BLVD STE 6
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1717
Practice Address - Country:US
Practice Address - Phone:561-508-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN240991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice