Provider Demographics
NPI:1225233778
Name:GHAZINOURI, ROSHANAK (DMD)
Entity Type:Individual
Prefix:
First Name:ROSHANAK
Middle Name:
Last Name:GHAZINOURI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1704
Mailing Address - Country:US
Mailing Address - Phone:617-256-6259
Mailing Address - Fax:
Practice Address - Street 1:1037 BEACON ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5656
Practice Address - Country:US
Practice Address - Phone:617-738-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0275506Medicaid