Provider Demographics
NPI:1811103732
Name:TAVARY, BERT ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:ANTHONY
Last Name:TAVARY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ANASTASIA BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4616
Mailing Address - Country:US
Mailing Address - Phone:904-824-3540
Mailing Address - Fax:904-824-3541
Practice Address - Street 1:700 ANASTASIA BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-4616
Practice Address - Country:US
Practice Address - Phone:904-824-3540
Practice Address - Fax:904-824-3541
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 86271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice