Provider Demographics
NPI:1669968905
Name:ELBAHRI, MICHELINE BAZ (DDS)
Entity type:Individual
Prefix:
First Name:MICHELINE
Middle Name:BAZ
Last Name:ELBAHRI
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 1:12910 SHIREWOOD LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1655
Mailing Address - Country:US
Mailing Address - Phone:904-994-6754
Mailing Address - Fax:
Practice Address - Street 1:445 STATE ROAD 13 N STE 22
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-2821
Practice Address - Country:US
Practice Address - Phone:904-640-1362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL128911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice