Provider Demographics
NPI:1356480958
Name:FARAHANI, MITRA
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:FARAHANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROSECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-2434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 STATE ROUTE 101A
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-2274
Practice Address - Country:US
Practice Address - Phone:603-672-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1822124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist