Provider Demographics
NPI:1285352369
Name:IRANMANESH, NIKA
Entity type:Individual
Prefix:
First Name:NIKA
Middle Name:
Last Name:IRANMANESH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1853
Mailing Address - Country:US
Mailing Address - Phone:813-933-6705
Mailing Address - Fax:
Practice Address - Street 1:2814 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1853
Practice Address - Country:US
Practice Address - Phone:813-933-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist