Provider Demographics
NPI:1225411069
Name:TAHA, AHMED
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:
Last Name:TAHA
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 1:2117 DEERCROFT DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6349
Mailing Address - Country:US
Mailing Address - Phone:321-355-0482
Mailing Address - Fax:
Practice Address - Street 1:6050 BABCOCK ST SE STE 2
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-4203
Practice Address - Country:US
Practice Address - Phone:321-725-9946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111814100Medicaid