Provider Demographics
NPI:1932728078
Name:AZARI SAMANI, MOHAMMAD REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD REZA
Middle Name:
Last Name:AZARI SAMANI
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 1:14453 BEACH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2081
Mailing Address - Country:US
Mailing Address - Phone:904-992-8900
Mailing Address - Fax:
Practice Address - Street 1:14453 BEACH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-2081
Practice Address - Country:US
Practice Address - Phone:904-992-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN128601223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics