| Doctor Name: | DR. AMIR REZA ARDALAN |
| NPI Number: | 1093873820 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DMD |
| License Number: | DN16127 |
| Business Practice Address: | 374 Sw Prima Vista Blvd. Port St. Lucie, FL - 34983 |
| Business Phone Number: | 7723444664 |
| Business Fax Number: | 7726214498 |
| Mailing Address: | 833 Sw Grand Reserve Blvd, PORT ST LUCIE |
| State: | FL |
| Postal Code: | 349862341 |
| Phone Number: | 7728789617 |
| Fax Number: | 7728789617 |
| NPI Enumeration Date: | 12/05/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | DN16127 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |