Provider Demographics
NPI:1245761311
Name:FARZIN, MANOUSH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANOUSH
Middle Name:
Last Name:FARZIN
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 1:3930 S ALMA SCHOOL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4510
Mailing Address - Country:US
Mailing Address - Phone:480-222-8083
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:602-510-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0100741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice