Provider Demographics
NPI:1013695675
Name:OTARASHVILI, TEONA (DMD)
Entity Type:Individual
Prefix:DR
First Name:TEONA
Middle Name:
Last Name:OTARASHVILI
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 1:484 PARLIN ST FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3520
Mailing Address - Country:US
Mailing Address - Phone:267-206-0304
Mailing Address - Fax:
Practice Address - Street 1:484 PARLIN ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3520
Practice Address - Country:US
Practice Address - Phone:267-206-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI029864001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice