Provider Demographics
NPI:1538325865
Name:MAIRZADEH, FARINAZ GOLDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:FARINAZ
Middle Name:GOLDA
Last Name:MAIRZADEH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DICKS LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2004
Mailing Address - Country:US
Mailing Address - Phone:917-207-5634
Mailing Address - Fax:
Practice Address - Street 1:10 DICKS LN
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2004
Practice Address - Country:US
Practice Address - Phone:917-207-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0540061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03034457Medicaid