Provider Demographics
NPI:1932654035
Name:ALI BEHZADI, DMD., PA
Entity Type:Organization
Organization Name:ALI BEHZADI, DMD., PA
Other - Org Name:YOUR DOWNTOWN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAVICENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-831-4077
Mailing Address - Street 1:945 STATE ROAD 436
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5662
Mailing Address - Country:US
Mailing Address - Phone:407-831-4077
Mailing Address - Fax:
Practice Address - Street 1:945 STATE ROAD 436
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5662
Practice Address - Country:US
Practice Address - Phone:407-831-4077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155361223G0001X
FLDN190471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002483500Medicaid
FL002483900Medicaid