Provider Demographics
NPI:1053207175
Name:FAROKHROU, SHAYEGAN
Entity type:Individual
Prefix:
First Name:SHAYEGAN
Middle Name:
Last Name:FAROKHROU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 E IRLO BRONSON MEMORIAL HWY STE C-106
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5401
Mailing Address - Country:US
Mailing Address - Phone:407-935-1772
Mailing Address - Fax:
Practice Address - Street 1:2310 E IRLO BRONSON MEMORIAL HWY STE C-106
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5401
Practice Address - Country:US
Practice Address - Phone:407-935-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN30389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist