Provider Demographics
NPI:1043368343
Name:AMIR R FEREYDOUNI DMD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:AMIR R FEREYDOUNI DMD PROFESSIONAL CORPORATION
Other - Org Name:KIDS & FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-738-8828
Mailing Address - Street 1:8199 SOUTHPARK LN
Mailing Address - Street 2:SUITE #150
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8199 SOUTHPARK LN
Practice Address - Street 2:SUITE #150
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5667
Practice Address - Country:US
Practice Address - Phone:303-738-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO84951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90323840Medicaid