Provider Demographics
NPI:1518319250
Name:KHEZRI, OMID (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:KHEZRI
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 1:3135 COLUMBIA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7833
Mailing Address - Country:US
Mailing Address - Phone:321-567-2000
Mailing Address - Fax:321-567-2070
Practice Address - Street 1:3135 COLUMBIA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7833
Practice Address - Country:US
Practice Address - Phone:321-567-2000
Practice Address - Fax:321-567-2070
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist