Provider Demographics
NPI:1275653198
Name:MIRESMAILI, MANDANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANDANA
Middle Name:
Last Name:MIRESMAILI
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 1:65 E INDIA ROW
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-3308
Mailing Address - Country:US
Mailing Address - Phone:617-680-2441
Mailing Address - Fax:
Practice Address - Street 1:302 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-2389
Practice Address - Country:US
Practice Address - Phone:781-233-0344
Practice Address - Fax:781-233-0344
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice