Provider Demographics
NPI:1114031838
Name:JABBARY, REZA
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:JABBARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 S UNIVERSITY DR APT 7107
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1457
Mailing Address - Country:US
Mailing Address - Phone:954-723-7907
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052823-11223G0001X
FLDN176051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice