Provider Demographics
NPI:1578659736
Name:ABEDI, REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:ABEDI
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 1:879 N PLAZA DR
Mailing Address - Street 2:E101
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85220-4152
Mailing Address - Country:US
Mailing Address - Phone:480-288-5955
Mailing Address - Fax:480-288-4345
Practice Address - Street 1:879 N PLAZA DR
Practice Address - Street 2:E014
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-4152
Practice Address - Country:US
Practice Address - Phone:480-288-5955
Practice Address - Fax:480-288-4345
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ640658Medicaid