Provider Demographics
NPI:1407551401
Name:MOSHAEINEZHAD, NASTARAN (DDS)
Entity Type:Individual
Prefix:
First Name:NASTARAN
Middle Name:
Last Name:MOSHAEINEZHAD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:MOSHAEINEZHAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MPH
Mailing Address - Street 1:845 BLUFFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5268
Mailing Address - Country:US
Mailing Address - Phone:718-808-3942
Mailing Address - Fax:
Practice Address - Street 1:1209 N RETAIL CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-9626
Practice Address - Country:US
Practice Address - Phone:843-357-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCDGD.105961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program