Provider Demographics
NPI:1093085284
Name:GOHARI, KHOSROW (DMD)
Entity Type:Individual
Prefix:MR
First Name:KHOSROW
Middle Name:
Last Name:GOHARI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MADISON AVE.
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:212-682-7254
Mailing Address - Fax:212-810-4090
Practice Address - Street 1:301 MADISON AVE.
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:212-682-7254
Practice Address - Fax:212-810-4090
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043702-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice