Provider Demographics
NPI:1033329230
Name:ABDOLLAHI, MITRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:ABDOLLAHI
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 1:3 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-1740
Mailing Address - Country:US
Mailing Address - Phone:856-782-0800
Mailing Address - Fax:856-782-7868
Practice Address - Street 1:3 N WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1740
Practice Address - Country:US
Practice Address - Phone:856-782-0800
Practice Address - Fax:856-782-7868
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD0191601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6618901Medicaid
NJ1035795Medicaid