Provider Demographics
NPI:1326037250
Name:KHESHTCHIN, MANDANA (DDS)
Entity Type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:KHESHTCHIN
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 1:960 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-7808
Mailing Address - Country:US
Mailing Address - Phone:480-921-3811
Mailing Address - Fax:480-921-3830
Practice Address - Street 1:2626 S RURAL RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2431
Practice Address - Country:US
Practice Address - Phone:480-597-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice