Provider Demographics
NPI:1407041635
Name:KERMANSHAHCHI, MOZHGAN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MOZHGAN
Middle Name:
Last Name:KERMANSHAHCHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:KERMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1521 JERICHO TPK
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4712
Mailing Address - Country:US
Mailing Address - Phone:516-616-4900
Mailing Address - Fax:516-282-2500
Practice Address - Street 1:1521 JERICHO TPK
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4712
Practice Address - Country:US
Practice Address - Phone:516-616-4900
Practice Address - Fax:516-282-2500
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04539011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01505095Medicaid