Provider Demographics
NPI:1225096720
Name:FATAHZADEH, MAHNAZ (DMD)
Entity type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:FATAHZADEH
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 1:15 JON LEIF LANE
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977
Mailing Address - Country:US
Mailing Address - Phone:865-356-6084
Mailing Address - Fax:973-972-0505
Practice Address - Street 1:110 BEGERN STREET
Practice Address - Street 2:NJ DENTAL SCHOOL ORAL MEDICINE CLINIC D LEVEL AREA 12
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-1956
Practice Address - Fax:973-972-0505
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI020908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist