Provider Demographics
NPI:1376038547
Name:MIRKHESHTI, MARJAN (DMD)
Entity Type:Individual
Prefix:
First Name:MARJAN
Middle Name:
Last Name:MIRKHESHTI
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 1:8220 LAKEWOOD RANCH BLVD UNIT 302
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5266
Mailing Address - Country:US
Mailing Address - Phone:678-860-8047
Mailing Address - Fax:
Practice Address - Street 1:250 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2340
Practice Address - Country:US
Practice Address - Phone:386-626-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN235761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice