Provider Demographics
NPI:1114059201
Name:REZA AZARI SAMANI, DDS PA
Entity Type:Organization
Organization Name:REZA AZARI SAMANI, DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:AZARI
Authorized Official - Last Name:SAMANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-992-8900
Mailing Address - Street 1:14453 BEACH BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-992-8900
Mailing Address - Fax:904-992-4922
Practice Address - Street 1:14453 BEACH BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-992-8900
Practice Address - Fax:904-992-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL128601223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
69855OtherBLUE CROSS BLUE SHIELD
826747OtherUNITED CONCORDIA