Provider Demographics
NPI:1174046262
Name:MIRZAI, JAVAD
Entity Type:Individual
Prefix:
First Name:JAVAD
Middle Name:
Last Name:MIRZAI
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 RIVERSIDE AVE UNIT 318
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02746-5441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 RIVERSIDE AVE UNIT 318
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02746-5441
Practice Address - Country:US
Practice Address - Phone:617-877-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist