Provider Demographics
NPI:1154439628
Name:AMIN, ATM N (BDS)
Entity Type:Individual
Prefix:
First Name:ATM
Middle Name:N
Last Name:AMIN
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 PALM BAY RD NE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3071
Mailing Address - Country:US
Mailing Address - Phone:321-724-5100
Mailing Address - Fax:321-724-5139
Practice Address - Street 1:1890 PALM BAY RD NE
Practice Address - Street 2:SUITE 2
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3071
Practice Address - Country:US
Practice Address - Phone:321-724-5100
Practice Address - Fax:321-724-5139
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL077777300Medicaid