Provider Demographics
NPI:1164533550
Name:MIREMAMI, REZA
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MIREMAMI
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 1:2245 VERNON OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4468
Mailing Address - Country:US
Mailing Address - Phone:404-642-4447
Mailing Address - Fax:
Practice Address - Street 1:2245 VERNON OAKS WAY
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4468
Practice Address - Country:US
Practice Address - Phone:404-642-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice