Provider Demographics
NPI:1235667304
Name:MIRZA, SHIFAT HOSSAIN (DDS)
Entity Type:Individual
Prefix:
First Name:SHIFAT
Middle Name:HOSSAIN
Last Name:MIRZA
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 1:1200 CORPORATE CENTER WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2108
Mailing Address - Country:US
Mailing Address - Phone:561-798-0100
Mailing Address - Fax:
Practice Address - Street 1:1200 CORPORATE CENTER WAY STE 103
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-2108
Practice Address - Country:US
Practice Address - Phone:561-798-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24558122300000X
PADS0418191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist