Provider Demographics
NPI:1083051106
Name:AZAM, SHABANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHABANA
Middle Name:
Last Name:AZAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHABANA
Other - Middle Name:
Other - Last Name:AZAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3135 THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-6256
Mailing Address - Country:US
Mailing Address - Phone:850-588-5256
Mailing Address - Fax:850-775-4154
Practice Address - Street 1:3135 THOMAS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-6256
Practice Address - Country:US
Practice Address - Phone:850-588-5256
Practice Address - Fax:850-775-4154
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21078122300000X
FLDN21078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist