Provider Demographics
NPI:1730655192
Name:BANASSER, ABDULAZIZ (BDS)
Entity Type:Individual
Prefix:
First Name:ABDULAZIZ
Middle Name:
Last Name:BANASSER
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CENTER DR GAINESVILLE FL 32610-3006
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0001
Mailing Address - Country:US
Mailing Address - Phone:352-273-6683
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM17921223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDRPM1792OtherFLORIDA DEPARTMENT OF HEALTH