Provider Demographics
NPI:1093726846
Name:DAVANLOU, AZITA (DDS)
Entity Type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:DAVANLOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 PFEFFERKORN ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST FRIENDSHIP
Mailing Address - State:MD
Mailing Address - Zip Code:21794
Mailing Address - Country:US
Mailing Address - Phone:410-489-9860
Mailing Address - Fax:410-489-9861
Practice Address - Street 1:8180 LARK BROWN ROAD
Practice Address - Street 2:SUITE #202
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075
Practice Address - Country:US
Practice Address - Phone:410-799-7172
Practice Address - Fax:410-799-7132
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist