Provider Demographics
NPI:1326530460
Name:NEZAFAT, KASRA
Entity Type:Individual
Prefix:DR
First Name:KASRA
Middle Name:
Last Name:NEZAFAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 VERBENA DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6923
Mailing Address - Country:US
Mailing Address - Phone:678-699-9978
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1058
Practice Address - Country:US
Practice Address - Phone:770-517-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0156451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice