Provider Demographics
NPI:1356089395
Name:FARHADI AMIRI, POURIA (DMD)
Entity Type:Individual
Prefix:
First Name:POURIA
Middle Name:
Last Name:FARHADI AMIRI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 FORT BENNING RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31903-2834
Mailing Address - Country:US
Mailing Address - Phone:706-322-9599
Mailing Address - Fax:
Practice Address - Street 1:2607 GILLIONVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3003
Practice Address - Country:US
Practice Address - Phone:229-883-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist