Provider Demographics
NPI:1013396845
Name:DARVISHAN, BEHNAM (DMD)
Entity Type:Individual
Prefix:
First Name:BEHNAM
Middle Name:
Last Name:DARVISHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5430
Mailing Address - Country:US
Mailing Address - Phone:630-743-4500
Mailing Address - Fax:630-743-4940
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5430
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:630-743-4940
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190330241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice