Provider Demographics
NPI:1578734422
Name:AMIRI, SOUSAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:SOUSAN
Middle Name:M
Last Name:AMIRI
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 1:2308 BIG PINE DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-6762
Mailing Address - Country:US
Mailing Address - Phone:704-839-9401
Mailing Address - Fax:704-847-2087
Practice Address - Street 1:2308 BIG PINE DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-6762
Practice Address - Country:US
Practice Address - Phone:704-839-9401
Practice Address - Fax:704-847-2087
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice