Provider Demographics
NPI:1841212743
Name:TABA, FERESHTEH P (DDS)
Entity Type:Individual
Prefix:DR
First Name:FERESHTEH
Middle Name:P
Last Name:TABA
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 1:12420 SAN JOSE BLVD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2643
Mailing Address - Country:US
Mailing Address - Phone:904-268-3002
Mailing Address - Fax:904-880-5669
Practice Address - Street 1:12420 SAN JOSE BLVD
Practice Address - Street 2:SUITE ONE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2643
Practice Address - Country:US
Practice Address - Phone:904-268-3002
Practice Address - Fax:904-880-5669
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice