Provider Demographics
NPI:1467680504
Name:MOLAVI, SASAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SASAN
Middle Name:
Last Name:MOLAVI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 WASHINGTON AVE STE F2
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4000
Mailing Address - Country:US
Mailing Address - Phone:630-381-8281
Mailing Address - Fax:
Practice Address - Street 1:6100 WASHINGTON AVE STE F2
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4000
Practice Address - Country:US
Practice Address - Phone:262-999-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-28
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25283122300000X
IL019027961122300000X
NMDD3585122300000X
WI1001793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100076929Medicaid