Provider Demographics
NPI:1578143517
Name:MEHDI, SYED ALI AZAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:ALI AZAN
Last Name:MEHDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:SYED
Other - Middle Name:AZAN
Other - Last Name:MEHDI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:100 MAIN ST APT 508
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-6949
Mailing Address - Country:US
Mailing Address - Phone:860-940-9477
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST APT 508
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-6949
Practice Address - Country:US
Practice Address - Phone:860-940-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02830600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist