Provider Demographics
NPI:1811332356
Name:BERT A TAVARY, D.D.S., P.A.
Entity type:Organization
Organization Name:BERT A TAVARY, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAVARY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:904-824-3540
Mailing Address - Street 1:700 ANASTASIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4616
Mailing Address - Country:US
Mailing Address - Phone:904-824-3540
Mailing Address - Fax:
Practice Address - Street 1:700 ANASTASIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-4616
Practice Address - Country:US
Practice Address - Phone:904-824-3540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty