Provider Demographics
NPI:1164823365
Name:SHAHROKHI RAD, AFSANEH (DMD, MSC)
Entity Type:Individual
Prefix:
First Name:AFSANEH
Middle Name:
Last Name:SHAHROKHI RAD
Suffix:
Gender:F
Credentials:DMD, MSC
Other - Prefix:
Other - First Name:AFSANEH
Other - Middle Name:
Other - Last Name:RAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, MSC
Mailing Address - Street 1:188 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5819
Mailing Address - Country:US
Mailing Address - Phone:617-432-1434
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:HARVARD SCHOOL OF DENTAL MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL123971223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics