Provider Demographics
NPI:1407472335
Name:REZKALLA, MIRNA AZER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIRNA
Middle Name:AZER
Last Name:REZKALLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-343-2000
Mailing Address - Fax:
Practice Address - Street 1:1877 FORTUNE RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4428
Practice Address - Country:US
Practice Address - Phone:407-343-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD26206122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program