Provider Demographics
NPI:1083027197
Name:HALEH BAZARGAN DDS PLLC
Entity Type:Organization
Organization Name:HALEH BAZARGAN DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZARGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-388-0906
Mailing Address - Street 1:430 W FINNIE FLAT RD
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-7362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7362
Practice Address - Country:US
Practice Address - Phone:928-567-4108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8563122300000X
AZ2553122300000X
AZ83771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ729347Medicaid
AZ758643Medicaid