Provider Demographics
NPI:1427649755
Name:AGHAALIANDASTJERDI, ROZ (DMD)
Entity type:Individual
Prefix:
First Name:ROZ
Middle Name:
Last Name:AGHAALIANDASTJERDI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12341 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33323-1773
Mailing Address - Country:US
Mailing Address - Phone:954-218-9052
Mailing Address - Fax:
Practice Address - Street 1:4873 BELLE TERRE PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8696
Practice Address - Country:US
Practice Address - Phone:386-864-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367841223G0001X
FLDN25014122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty