Provider Demographics
NPI:1295590180
Name:MYRTAJ, FLAVIA
Entity type:Individual
Prefix:
First Name:FLAVIA
Middle Name:
Last Name:MYRTAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7551 CUMBERLAND RD APT 9
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-2004
Mailing Address - Country:US
Mailing Address - Phone:727-479-7643
Mailing Address - Fax:
Practice Address - Street 1:10427 SHELDON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-5110
Practice Address - Country:US
Practice Address - Phone:813-302-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN305611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program