Provider Demographics
NPI:1366035677
Name:LILLYBASH DENTAL STUDIO PLLC
Entity Type:Organization
Organization Name:LILLYBASH DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANOOSH
Authorized Official - Middle Name:SHIRAVAND
Authorized Official - Last Name:AMROOEI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-203-5291
Mailing Address - Street 1:4312 W SYLVAN RAMBLE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4316
Mailing Address - Country:US
Mailing Address - Phone:813-203-5291
Mailing Address - Fax:
Practice Address - Street 1:11280 BOYETTE RD
Practice Address - Street 2:SUIT #101
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569
Practice Address - Country:US
Practice Address - Phone:813-567-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty