Provider Demographics
NPI:1164975520
Name:MOSHIRI, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:MOSHIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 PALM BAY RD NE STE 185
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9184
Mailing Address - Country:US
Mailing Address - Phone:321-332-7375
Mailing Address - Fax:
Practice Address - Street 1:715 PALM BAY RD NE STE 185
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-9184
Practice Address - Country:US
Practice Address - Phone:321-332-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist