Provider Demographics
NPI:1043498306
Name:HATAM-EBRAHIMI, POUYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:POUYA
Middle Name:
Last Name:HATAM-EBRAHIMI
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 1:676 DEKALB PIKE
Mailing Address - Street 2:SUITE #207
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1223
Mailing Address - Country:US
Mailing Address - Phone:610-272-4482
Mailing Address - Fax:610-272-4484
Practice Address - Street 1:676 DEKALB PIKE
Practice Address - Street 2:SUITE #207
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1223
Practice Address - Country:US
Practice Address - Phone:610-272-4482
Practice Address - Fax:610-272-4484
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-029503-L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics