Provider Demographics
NPI:1245619212
Name:EHTESHAMI, SAMIRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMIRA
Middle Name:
Last Name:EHTESHAMI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 W COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-6015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 W COMMERCE CT
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-6015
Practice Address - Country:US
Practice Address - Phone:520-670-3758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-23
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ91681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice