Provider Demographics
NPI:1861987752
Name:IVANOV, SIMONA (DDS)
Entity type:Individual
Prefix:DR
First Name:SIMONA
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3415
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:813-405-3722
Practice Address - Street 1:302 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-866-0930
Practice Address - Fax:813-405-3722
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN233451223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health