Provider Demographics
NPI:1851479265
Name:KAWVEH NOFALLAH DMD PA
Entity Type:Organization
Organization Name:KAWVEH NOFALLAH DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAWVEH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOFALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-648-5338
Mailing Address - Street 1:3624 HARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5938
Mailing Address - Country:US
Mailing Address - Phone:863-648-5338
Mailing Address - Fax:863-648-5890
Practice Address - Street 1:3624 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5938
Practice Address - Country:US
Practice Address - Phone:863-648-5338
Practice Address - Fax:863-648-5890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 170751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty