Provider Demographics
NPI:1073662326
Name:MOGHADAM, MARJAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARJAN
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 64TH ST APT W3F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7862
Mailing Address - Country:US
Mailing Address - Phone:917-658-5863
Mailing Address - Fax:
Practice Address - Street 1:726 BROADWAY STE 350
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9502
Practice Address - Country:US
Practice Address - Phone:212-443-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0501581223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics