Provider Demographics
NPI:1568914851
Name:MAHDAVI, ASHKAN (DMD, MBA)
Entity Type:Individual
Prefix:DR
First Name:ASHKAN
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:M
Credentials:DMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 DEL MORENO PL
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4634
Mailing Address - Country:US
Mailing Address - Phone:818-346-4380
Mailing Address - Fax:
Practice Address - Street 1:10377 INDUSTRIAL BLVD NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1403
Practice Address - Country:US
Practice Address - Phone:770-222-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015279122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentist