Provider Demographics
NPI:1558717223
Name:CHABALLOUT, TASNEEEM (DDS)
Entity Type:Individual
Prefix:DR
First Name:TASNEEEM
Middle Name:
Last Name:CHABALLOUT
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 1:1704 GARDEN SAGE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-4617
Mailing Address - Country:US
Mailing Address - Phone:424-421-9102
Mailing Address - Fax:
Practice Address - Street 1:2119 W BRANDON BLVD STE F
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4731
Practice Address - Country:US
Practice Address - Phone:813-662-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN233201223G0001X
FL1508122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist