Provider Demographics
NPI:1346448701
Name:KHANBODAGHI, AZITA (DMD)
Entity Type:Individual
Prefix:DR
First Name:AZITA
Middle Name:
Last Name:KHANBODAGHI
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 1:15 N BEACON ST
Mailing Address - Street 2:#308
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice