Provider Demographics
NPI:1295823219
Name:BAGHERI, NAZILA MIRZA (DDS)
Entity Type:Individual
Prefix:
First Name:NAZILA
Middle Name:MIRZA
Last Name:BAGHERI
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:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:KEAMS CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:86034-0001
Mailing Address - Country:US
Mailing Address - Phone:928-737-6165
Mailing Address - Fax:
Practice Address - Street 1:MP 388 HIGHWAY 264
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA518941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice