Provider Demographics
NPI:1285758839
Name:PALM HARBOR DENTAL ASSOCIATES INC
Entity type:Organization
Organization Name:PALM HARBOR DENTAL ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SIAMAK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFIEIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-786-9144
Mailing Address - Street 1:34669 US HWY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-986-9144
Mailing Address - Fax:727-786-9155
Practice Address - Street 1:34669 US HWY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-986-9144
Practice Address - Fax:727-786-9155
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST PARK DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13918122300000X
FLDN3904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty