Provider Demographics
NPI:1275972390
Name:ATALLAH, AYMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AYMAN
Middle Name:
Last Name:ATALLAH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 NAUTICA DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7222
Mailing Address - Country:US
Mailing Address - Phone:800-965-6470
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:410 BLANDING BLVD STE 6B
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5065
Practice Address - Country:US
Practice Address - Phone:904-276-5950
Practice Address - Fax:904-276-5359
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN201911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice