Provider Demographics
NPI:1790331379
Name:YASSINE, SHADAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHADAN
Middle Name:
Last Name:YASSINE
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 1:433 APOLLO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2281
Mailing Address - Country:US
Mailing Address - Phone:813-341-0102
Mailing Address - Fax:
Practice Address - Street 1:433 APOLLO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2281
Practice Address - Country:US
Practice Address - Phone:813-341-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-10
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11590122300000X
FL243991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist