Provider Demographics
NPI:1073139184
Name:GHASSEMI, AVA (DMD)
Entity Type:Individual
Prefix:DR
First Name:AVA
Middle Name:
Last Name:GHASSEMI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:AVA
Other - Middle Name:
Other - Last Name:GHASSEMI-TARY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1765 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1535
Mailing Address - Country:US
Mailing Address - Phone:617-327-4321
Mailing Address - Fax:
Practice Address - Street 1:209 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5071
Practice Address - Country:US
Practice Address - Phone:617-277-3127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18591561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty