Provider Demographics
NPI:1083392476
Name:GAVAHI KASHANI, KEIHAN
Entity Type:Individual
Prefix:
First Name:KEIHAN
Middle Name:
Last Name:GAVAHI KASHANI
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 1:200 N 16TH ST APT 522
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1218
Mailing Address - Country:US
Mailing Address - Phone:615-767-0907
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-503-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS044223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist