Provider Demographics
NPI:1568138063
Name:HOSSEINKHANI HAZAVEH, MAHTA (DDS, MSC)
Entity Type:Individual
Prefix:DR
First Name:MAHTA
Middle Name:
Last Name:HOSSEINKHANI HAZAVEH
Suffix:
Gender:F
Credentials:DDS, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 FORNELIUS AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:63 FORNELIUS AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1846
Practice Address - Country:US
Practice Address - Phone:862-255-8968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014176161223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry