Provider Demographics
NPI:1891391793
Name:NASTAEIN, FARSHAD
Entity Type:Individual
Prefix:
First Name:FARSHAD
Middle Name:
Last Name:NASTAEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 PALM SPRINGS BLVD UNIT 11205
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-5022
Mailing Address - Country:US
Mailing Address - Phone:832-353-5729
Mailing Address - Fax:
Practice Address - Street 1:1912 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4700
Practice Address - Country:US
Practice Address - Phone:813-567-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27625124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist